MEDICARE: MADISON B HOLM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1801323712
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADISON B HOLM

Provider Business Mailing Address
First Line	:	6906 WINDWOOD DR
Second Line	:
City	:	LAKE ANN
State	:	MI
Zip	:	49650-9536
Country	:	US
Telephone Number	:	231-409-3559
Fax Number	:

Provider Business Practice Location Address
First Line	:	1363 DOUGLAS DR STE 104
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49696-8980
Country	:	US
Telephone Number	:	231-668-4909
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2017
Last Update Date	:	05/23/2017

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