Provider Demographics
NPI:1053050013
Name:WILMOTH, MADISON MARIE
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:MARIE
Last Name:WILMOTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1597 COVENT RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-2473
Mailing Address - Country:US
Mailing Address - Phone:937-570-7552
Mailing Address - Fax:
Practice Address - Street 1:3780 RIDGE MILL DR STE 100
Practice Address - Street 2:
Practice Address - City:HILLIARD
Practice Address - State:OH
Practice Address - Zip Code:43026-7458
Practice Address - Country:US
Practice Address - Phone:614-219-1510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-28
Last Update Date:2022-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician