Healthcare Provider Details

I. General information

NPI: 1750156097
Provider Name (Legal Business Name): MADISON GRACE PHILLIPS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2023
Last Update Date: 05/13/2025
Certification Date: 05/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9905 FALL CREEK RD
INDIANAPOLIS IN
46256-4804
US

IV. Provider business mailing address

320 N 21ST AVE
BEECH GROVE IN
46107-1026
US

V. Phone/Fax

Practice location:
  • Phone: 317-813-4690
  • Fax:
Mailing address:
  • Phone: 810-404-3538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-147549
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: