Provider Demographics
NPI:1104970631
Name:CHANG, MADELINE
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:CHANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 THE VLG
Mailing Address - Street 2:#206
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-2544
Mailing Address - Country:US
Mailing Address - Phone:310-376-9222
Mailing Address - Fax:
Practice Address - Street 1:520 N PROSPECT AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-3041
Practice Address - Country:US
Practice Address - Phone:310-376-9222
Practice Address - Fax:310-376-9888
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT 2596225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist