Provider Demographics
NPI:1528874203
Name:HIMMELREICH, MADISON
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:HIMMELREICH
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 1:195 SCOTTSDALE DR
Mailing Address - Street 2:
Mailing Address - City:MIFFLINBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17844-9415
Mailing Address - Country:US
Mailing Address - Phone:570-428-3853
Mailing Address - Fax:
Practice Address - Street 1:195 SCOTTSDALE DR
Practice Address - Street 2:
Practice Address - City:MIFFLINBURG
Practice Address - State:PA
Practice Address - Zip Code:17844-9415
Practice Address - Country:US
Practice Address - Phone:570-428-3853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-06
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI006601225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant