Provider Demographics
NPI:1538996046
Name:LANE, MADISON ABIGAIL (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:ABIGAIL
Last Name:LANE
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1270 HILLCREST DR APT 4408
Mailing Address - Street 2:
Mailing Address - City:SUGAR HILL
Mailing Address - State:GA
Mailing Address - Zip Code:30518-3740
Mailing Address - Country:US
Mailing Address - Phone:540-632-3543
Mailing Address - Fax:
Practice Address - Street 1:125 SAMARITAN DR
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2354
Practice Address - Country:US
Practice Address - Phone:770-889-0120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-18
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT009337225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist