Healthcare Provider Details

I. General information

NPI: 1316793946
Provider Name (Legal Business Name): MADISON MAHLENDORF
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2024
Last Update Date: 04/25/2024
Certification Date: 04/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 N MAIN ST
KISSIMMEE FL
34744-3304
US

IV. Provider business mailing address

3080 STATION SQ APT 2-400
KISSIMMEE FL
34744-1653
US

V. Phone/Fax

Practice location:
  • Phone: 407-785-1009
  • Fax:
Mailing address:
  • Phone: 610-816-4319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: