Healthcare Provider Details

I. General information

NPI: 1952205809
Provider Name (Legal Business Name): CHRISTINA MADISON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1251 COUNTY ROAD B2 W
ROSEVILLE MN
55113-3205
US

IV. Provider business mailing address

1299 RUGGLES ST
ROSEVILLE MN
55113-6169
US

V. Phone/Fax

Practice location:
  • Phone: 612-718-4920
  • Fax:
Mailing address:
  • Phone: 612-718-4920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number475429
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: