Provider Demographics
NPI:1649647116
Name:MILICI, MADISON (PT, DPT, RYT)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:MILICI
Suffix:
Gender:F
Credentials:PT, DPT, RYT
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:
Other - Last Name:GOLDIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 471
Mailing Address - Street 2:
Mailing Address - City:CARDIFF BY THE SEA
Mailing Address - State:CA
Mailing Address - Zip Code:92007-0471
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2063 SAN ELIJO AVE
Practice Address - Street 2:
Practice Address - City:CARDIFF BY THE SEA
Practice Address - State:CA
Practice Address - Zip Code:92007-1726
Practice Address - Country:US
Practice Address - Phone:760-692-4735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-31
Last Update Date:2020-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT42780225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist