Provider Demographics
NPI:1730771825
Name:MALCOLM, MADISON NICOLE (COTA/L)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:NICOLE
Last Name:MALCOLM
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 N PERKINS RD STE F
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74075-5524
Mailing Address - Country:US
Mailing Address - Phone:405-564-2701
Mailing Address - Fax:888-581-6850
Practice Address - Street 1:120 N PERKINS RD STE F
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74075-5524
Practice Address - Country:US
Practice Address - Phone:405-564-2701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-09
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2281224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK2281OtherCOTA/L