Provider Demographics
NPI:1164296745
Name:HEATON, MADISON
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:HEATON
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 1:189 WABEENO TRL
Mailing Address - Street 2:
Mailing Address - City:MEDFORD LAKES
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-1319
Mailing Address - Country:US
Mailing Address - Phone:609-678-5808
Mailing Address - Fax:
Practice Address - Street 1:20531 DARDEN RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46637-2915
Practice Address - Country:US
Practice Address - Phone:574-272-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-14
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR01141200225X00000X
VT072.0134420225X00000X
IN31008690A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist