Provider Demographics
NPI:1720820343
Name:BURTON, MADISON BROOKE
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:BROOKE
Last Name:BURTON
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 1:1011 W WILLIAMS ST STE G
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3564
Mailing Address - Country:US
Mailing Address - Phone:208-991-0222
Mailing Address - Fax:208-344-0014
Practice Address - Street 1:1011 W WILLIAMS ST STE G
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-3564
Practice Address - Country:US
Practice Address - Phone:208-991-0222
Practice Address - Fax:208-344-0014
Is Sole Proprietor?:No
Enumeration Date:2024-06-12
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-10313101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health