Healthcare Provider Details

I. General information

NPI: 1689306854
Provider Name (Legal Business Name): MADISON RAE TREACY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2022
Last Update Date: 06/27/2022
Certification Date: 06/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1557 PINE MARSH LOOP
SAINT CLOUD FL
34771-7407
US

IV. Provider business mailing address

1557 PINE MARSH LOOP
SAINT CLOUD FL
34771-7407
US

V. Phone/Fax

Practice location:
  • Phone: 407-446-5350
  • Fax: 407-960-3009
Mailing address:
  • Phone: 407-446-5350
  • Fax: 407-960-3009

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: