Healthcare Provider Details

I. General information

NPI: 1821805904
Provider Name (Legal Business Name): MADELINE TAYLOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2024
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1119 W KENNEDY AVE STE A
KIMBERLY WI
54136-2213
US

IV. Provider business mailing address

PO BOX 309
SIREN WI
54872-0309
US

V. Phone/Fax

Practice location:
  • Phone: 920-336-8960
  • Fax:
Mailing address:
  • Phone: 715-327-7112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12314-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: