Healthcare Provider Details

I. General information

NPI: 1639748148
Provider Name (Legal Business Name): MADISON WHITLEY M.A., BCBA, COBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2021
Last Update Date: 02/22/2023
Certification Date: 02/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6960 S EDGERTON RD
BRECKSVILLE OH
44141-3184
US

IV. Provider business mailing address

1216 BARKER BLVD APT A
KENT OH
44240-8618
US

V. Phone/Fax

Practice location:
  • Phone: 440-241-8366
  • Fax:
Mailing address:
  • Phone: 910-787-7466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-22-62073
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: