Provider Demographics
NPI:1982444501
Name:MAINARD, MADISON (OTR/L, CLT)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:MAINARD
Suffix:
Gender:F
Credentials:OTR/L, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3719 N BENNETT ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98407-3536
Mailing Address - Country:US
Mailing Address - Phone:253-250-6039
Mailing Address - Fax:
Practice Address - Street 1:2121 S MERIDIAN
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98371-7506
Practice Address - Country:US
Practice Address - Phone:253-904-3535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-30
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT61256096225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist