Healthcare Provider Details

I. General information

NPI: 1104525138
Provider Name (Legal Business Name): MADISON HURST RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2023
Last Update Date: 02/28/2023
Certification Date: 02/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 W BRADLEY AVE
CHAMPAIGN IL
61821-1849
US

IV. Provider business mailing address

215 RED COACH DR
MISHAWAKA IN
46545-8307
US

V. Phone/Fax

Practice location:
  • Phone: 574-387-4313
  • Fax:
Mailing address:
  • Phone: 574-387-4313
  • Fax: 574-204-2868

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: