Provider Demographics
NPI:1427689827
Name:PETERSON, MADALYN R (OTD)
Entity type:Individual
Prefix:
First Name:MADALYN
Middle Name:R
Last Name:PETERSON
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3204 VISTA DR
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-3845
Mailing Address - Country:US
Mailing Address - Phone:916-205-0066
Mailing Address - Fax:
Practice Address - Street 1:11840 S LA CIENEGA BLVD
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-3459
Practice Address - Country:US
Practice Address - Phone:424-269-3400
Practice Address - Fax:310-882-5451
Is Sole Proprietor?:No
Enumeration Date:2020-02-04
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21434225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist