MEDICARE: MS. SHARDAE MADISON RBT

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	106S00000X	Behavior Technician	21151047	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629731740
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SHARDAE MADISON RBT

Provider Business Mailing Address
First Line	:	1240 S NOVA RD APT 119
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32114-5886
Country	:	US
Telephone Number	:	248-935-8231
Fax Number	:

Provider Business Practice Location Address
First Line	:	1240 S NOVA RD APT 119
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32114-5886
Country	:	US
Telephone Number	:	248-935-8231
Fax Number	:

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

Provider Enumeration Date	:	10/15/2021
Last Update Date	:	10/15/2021

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