Healthcare Provider Details

I. General information

NPI: 1316582182
Provider Name (Legal Business Name): MADISON WAGNER BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2019
Last Update Date: 10/07/2025
Certification Date: 10/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 3 MILE ROAD NW STE 200
GRAND RAPIDS MI
49544-1691
US

IV. Provider business mailing address

1188 COBB DR SE APT 3B
GRAND RAPIDS MI
49508-7364
US

V. Phone/Fax

Practice location:
  • Phone: 855-832-6727
  • Fax:
Mailing address:
  • Phone: 815-575-3338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: