Healthcare Provider Details

I. General information

NPI: 1972295020
Provider Name (Legal Business Name): MIA MADIGAN - PEREA BT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2023
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 COUNTY ROAD 42A
ALCALDE NM
87511-8829
US

IV. Provider business mailing address

PO BOX 28164
SANTA FE NM
87592-8164
US

V. Phone/Fax

Practice location:
  • Phone: 585-480-6824
  • Fax: 505-355-1808
Mailing address:
  • Phone: 585-480-6824
  • Fax: 505-355-1808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: