Provider Demographics
NPI:1871356550
Name:ROGAN, MADISON (OTR/L)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:ROGAN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 KENILWORTH AVE APT 174
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-0068
Mailing Address - Country:US
Mailing Address - Phone:706-308-4581
Mailing Address - Fax:
Practice Address - Street 1:2110 BEN CRAIG DR STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-2302
Practice Address - Country:US
Practice Address - Phone:704-595-9363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC16569225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist