MEDICARE: MADISON SOUTHALL

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

General Provider Information

NPI Number	:	1629923818
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADISON SOUTHALL

Provider Business Mailing Address
First Line	:	10101 FONDREN RD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77096-4564
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10101 FONDREN RD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77096-4564
Country	:	US
Telephone Number	:	404-487-6005
Fax Number	:

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

Provider Enumeration Date	:	03/03/2026
Last Update Date	:	03/03/2026

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Directions to “ MADISON SOUTHALL ” Practice Location

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