Healthcare Provider Details

I. General information

NPI: 1316630072
Provider Name (Legal Business Name): MADISON ASHLEE BOWLING
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2023
Last Update Date: 05/30/2023
Certification Date: 05/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11755 SOUTHWEST HWY
PALOS HEIGHTS IL
60463-1015
US

IV. Provider business mailing address

5274 W 90TH ST
OAK LAWN IL
60453-1312
US

V. Phone/Fax

Practice location:
  • Phone: 708-586-4239
  • Fax:
Mailing address:
  • Phone: 269-779-5122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: