Provider Demographics
NPI:1932920253
Name:WHEELER, MADISON BLAYNE
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:BLAYNE
Last Name:WHEELER
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 1:11983 TAMIAMI TRL N # 121
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34110-1603
Mailing Address - Country:US
Mailing Address - Phone:800-875-1871
Mailing Address - Fax:800-875-1871
Practice Address - Street 1:11983 TAMIAMI TRL N
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34110-1603
Practice Address - Country:US
Practice Address - Phone:800-875-1871
Practice Address - Fax:800-875-1871
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-19
Last Update Date:2024-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCRBT-24-330911106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician