Healthcare Provider Details

I. General information

NPI: 1780246298
Provider Name (Legal Business Name): MADISON LYNN HEPBURN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2019
Last Update Date: 11/03/2020
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 N PATTERSON ST
VALDOSTA GA
31601-4528
US

IV. Provider business mailing address

PO BOX 10827
TALLAHASSEE FL
32302-2827
US

V. Phone/Fax

Practice location:
  • Phone: 904-619-8430
  • Fax:
Mailing address:
  • Phone: 850-521-0242
  • Fax: 850-521-1973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number19-90727
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: