Provider Demographics
NPI:1699438507
Name:BEATY, MADDISON G
Entity type:Individual
Prefix:
First Name:MADDISON
Middle Name:G
Last Name:BEATY
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 1:90 HOWARD DR
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065-8138
Mailing Address - Country:US
Mailing Address - Phone:502-633-1007
Mailing Address - Fax:502-805-1511
Practice Address - Street 1:199 HENSLEE DR
Practice Address - Street 2:
Practice Address - City:DICKSON
Practice Address - State:TN
Practice Address - Zip Code:37055-2076
Practice Address - Country:US
Practice Address - Phone:615-652-1082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-18
Last Update Date:2024-12-12
Deactivation Date:2024-10-01
Deactivation Code:
Reactivation Date:2024-12-09
Provider Licenses
StateLicense IDTaxonomies
TN1681103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst