Provider Demographics
NPI:1790407104
Name:MISENHEIMER, MADISON (OTR/L)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:MISENHEIMER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 W MORRIS BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37813-2237
Mailing Address - Country:US
Mailing Address - Phone:423-375-8907
Mailing Address - Fax:423-822-5514
Practice Address - Street 1:263 E BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37760-2810
Practice Address - Country:US
Practice Address - Phone:865-375-0880
Practice Address - Fax:423-317-7773
Is Sole Proprietor?:No
Enumeration Date:2022-09-13
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7416225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7416OtherLICENSE