Provider Demographics
NPI:1760217145
Name:FREMEN, MADISON (PTA)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:FREMEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 VALLEY VIEW CIR APT 3109
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-4086
Mailing Address - Country:US
Mailing Address - Phone:985-722-8547
Mailing Address - Fax:
Practice Address - Street 1:5948 N MARKET ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-2017
Practice Address - Country:US
Practice Address - Phone:318-375-0001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-04
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA11602225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant