Healthcare Provider Details

I. General information

NPI: 1225534985
Provider Name (Legal Business Name): MADISON LYNNE NELSON RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 04/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 S RANCHO DR STE A
LAS VEGAS NV
89106-4849
US

IV. Provider business mailing address

PO BOX 516558
LOS ANGELES CA
90051-0596
US

V. Phone/Fax

Practice location:
  • Phone: 702-998-9505
  • Fax: 702-527-7939
Mailing address:
  • Phone: 702-671-5005
  • Fax: 702-895-4014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number17-46639
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: