Provider Demographics
NPI:1336922756
Name:CANTERBURY, MADISON
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:CANTERBURY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4907 NW 43RD ST STE C
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-2007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6976 PROFESSIONAL PKWY
Practice Address - Street 2:
Practice Address - City:LAKEWOOD RANCH
Practice Address - State:FL
Practice Address - Zip Code:34240-8414
Practice Address - Country:US
Practice Address - Phone:941-308-4641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-17
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty