Provider Demographics
NPI:1073228029
Name:TOLLEY, MADISON ALEXANDRIA
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:ALEXANDRIA
Last Name:TOLLEY
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 1:5973 KENVILLE GREEN CIR
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-7128
Mailing Address - Country:US
Mailing Address - Phone:336-251-1180
Mailing Address - Fax:
Practice Address - Street 1:905 FRIEDBERG CHURCH RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27127-9803
Practice Address - Country:US
Practice Address - Phone:336-251-1180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-13
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician