Provider Demographics
NPI:1881421436
Name:DIAZ, MADISON ROSE (OTR/L)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:ROSE
Last Name:DIAZ
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 1:2244 ELM PL
Mailing Address - Street 2:
Mailing Address - City:NORTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76247-1999
Mailing Address - Country:US
Mailing Address - Phone:501-765-6185
Mailing Address - Fax:
Practice Address - Street 1:2620 SCRIPTURE ST
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-4315
Practice Address - Country:US
Practice Address - Phone:940-297-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX124808225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist