MEDICARE: MADISON WAREHAM

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	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1578417036
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADISON WAREHAM

Provider Business Mailing Address
First Line	:	11703 S HARVEST MOON CT
Second Line	:
City	:	SOUTH JORDAN
State	:	UT
Zip	:	84009-8006
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11703 S HARVEST MOON CT
Second Line	:
City	:	SOUTH JORDAN
State	:	UT
Zip	:	84009-8006
Country	:	US
Telephone Number	:	801-427-3803
Fax Number	:

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

Provider Enumeration Date	:	02/23/2026
Last Update Date	:	02/23/2026

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