Healthcare Provider Details

I. General information

NPI: 1104744002
Provider Name (Legal Business Name): MADISON WAMBLES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2026
Last Update Date: 07/08/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 WEST LAWERANCE HARRIS HWY 52
SLOCOMB AL
36375
US

IV. Provider business mailing address

427 WEST LAWERANCE HARRIS HWY 52
SLOCOMB AL
36375
US

V. Phone/Fax

Practice location:
  • Phone: 334-618-3302
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number20-109628
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: