Provider Demographics
NPI:1881330322
Name:WELLS, MADISON BETH (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:MADISON
Middle Name:BETH
Last Name:WELLS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 E ELM ST
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-4426
Mailing Address - Country:US
Mailing Address - Phone:618-781-3236
Mailing Address - Fax:
Practice Address - Street 1:1111 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-5589
Practice Address - Country:US
Practice Address - Phone:618-692-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL470667224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant