Provider Demographics
NPI:1720894850
Name:ANDERSON, MADELINE
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:ANDERSON
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 1:623 SW MOUNT OLIVE CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:LAMONT
Mailing Address - State:FL
Mailing Address - Zip Code:32336-5014
Mailing Address - Country:US
Mailing Address - Phone:561-690-7316
Mailing Address - Fax:
Practice Address - Street 1:623 SW MOUNT OLIVE CHURCH RD
Practice Address - Street 2:
Practice Address - City:LAMONT
Practice Address - State:FL
Practice Address - Zip Code:32336-5014
Practice Address - Country:US
Practice Address - Phone:561-690-7316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-04
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician