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General NPI Number Information
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NPI Number | 1316582182
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Entity Type | Individual
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Provider Name | MADISON WAGNER BCBA
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Gender | Female
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Dates
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Enumeration Date | 11/15/2019
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Last Update Date | 10/07/2025
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Provider Practice Location Address
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Address Line | 600 3 MILE ROAD NW STE 200
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City | GRAND RAPIDS
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State | MI
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Zip | 49544-1691
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Country | US
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Telephone | 855-832-6727
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Fax |
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Provider Business Mailing Address
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Address Line | 1188 COBB DR SE APT 3B
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City | GRAND RAPIDS
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State | MI
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Zip | 49508-7364
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Country | US
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Telephone | 815-575-3338
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number |
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License Number State |
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