Healthcare Provider Details

I. General information

NPI: 1811539281
Provider Name (Legal Business Name): MADISON RAGAN HOOVER RUSSELL M.S., BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MADISON RAGAN HOOVER

II. Dates (important events)

Enumeration Date: 10/17/2019
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 MARY ALICE PARK RD STE 304
CUMMING GA
30040-2683
US

IV. Provider business mailing address

101 SHARON TRL
SUWANEE GA
30024-1301
US

V. Phone/Fax

Practice location:
  • Phone: 443-414-1843
  • Fax:
Mailing address:
  • Phone: 404-808-9945
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-24-73418
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: