=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952129884
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MADISON M REA ED.S., NCSP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2024
-----------------------------------------------------
Last Update Date | 09/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9750 SORENG AVE
-----------------------------------------------------
City | SCHILLER PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60176-2105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-678-2916
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1052 N LEAVITT ST APT 1
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60622-3523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-277-0508
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number | 1421040
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------