Provider Demographics
NPI:1649888447
Name:STATLANDER-KOTTKE, MADELINE (MA)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:STATLANDER-KOTTKE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-3333
Mailing Address - Country:US
Mailing Address - Phone:507-390-0058
Mailing Address - Fax:
Practice Address - Street 1:1414 S OAK AVE STE 6
Practice Address - Street 2:
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-3957
Practice Address - Country:US
Practice Address - Phone:507-390-0058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-17
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty