MEDICARE: DR. THERESA MADISON PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1154620656
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THERESA MADISON PHD

Provider Business Mailing Address
First Line	:	4808 MANDURIA ST
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32819-8428
Country	:	US
Telephone Number	:	407-970-2329
Fax Number	:

Provider Business Practice Location Address
First Line	:	4808 MANDURIA ST
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32819-8428
Country	:	US
Telephone Number	:	407-970-2329
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/23/2011
Last Update Date	:	03/23/2011

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