Provider Demographics
NPI:1093583718
Name:ALTAMIRANO, MADISON (RBT)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:ALTAMIRANO
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4920 ROSWELL RD STE 1
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-2684
Mailing Address - Country:US
Mailing Address - Phone:470-258-4050
Mailing Address - Fax:
Practice Address - Street 1:7000 LAKE ELLENOR DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-5749
Practice Address - Country:US
Practice Address - Phone:321-655-6585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-12
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-309640106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician