Provider Demographics
NPI:1306963459
Name:MADDEN, MONIQUE KEALANI (PTA)
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:KEALANI
Last Name:MADDEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 WILLIAM STREET EXT
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:CT
Mailing Address - Zip Code:06480-1659
Mailing Address - Country:US
Mailing Address - Phone:860-342-1025
Mailing Address - Fax:
Practice Address - Street 1:72 SALMON BROOK DR
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-2131
Practice Address - Country:US
Practice Address - Phone:860-633-5244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000911225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant