Healthcare Provider Details

I. General information

NPI: 1477474203
Provider Name (Legal Business Name): LEILA MAADOOLIAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2026
Last Update Date: 07/25/2026
Certification Date: 07/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 W BAYSIDE DR UNIT 302
GLENDALE WI
53217-1560
US

IV. Provider business mailing address

225 W BAYSIDE DR UNIT 302
GLENDALE WI
53217-1560
US

V. Phone/Fax

Practice location:
  • Phone: 262-302-0984
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-528678
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: