Provider Demographics
NPI:1154918894
Name:MILLICK, MADISON MAE
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:MAE
Last Name:MILLICK
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 1:3463 N 1375 W
Mailing Address - Street 2:
Mailing Address - City:LINTON
Mailing Address - State:IN
Mailing Address - Zip Code:47441-6050
Mailing Address - Country:US
Mailing Address - Phone:812-699-1852
Mailing Address - Fax:
Practice Address - Street 1:9800 OUTER LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-2440
Practice Address - Country:US
Practice Address - Phone:812-573-0088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant