Provider Demographics
NPI:1295440980
Name:GANZ, MADELINE GRACE (MSAT STUDENT)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:GRACE
Last Name:GANZ
Suffix:
Gender:F
Credentials:MSAT STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47408-1578
Mailing Address - Country:US
Mailing Address - Phone:812-855-1966
Mailing Address - Fax:
Practice Address - Street 1:701 E 17TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408-1578
Practice Address - Country:US
Practice Address - Phone:812-855-1966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN2000870419OtherSTUDENT ID