Healthcare Provider Details

I. General information

NPI: 1376017426
Provider Name (Legal Business Name): MADISAN MAE HERSLEBS MS, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2019
Last Update Date: 10/09/2024
Certification Date: 10/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

273 QUILLIAN STREET
CLEVELAND GA
30528
US

IV. Provider business mailing address

125 WIND FOREST CT
CLARKESVILLE GA
30523
US

V. Phone/Fax

Practice location:
  • Phone: 706-865-6800
  • Fax:
Mailing address:
  • Phone: 770-823-0954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP013246
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: