Provider Demographics
NPI:1184204448
Name:MCRAE, MADISON TAYLOR
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:TAYLOR
Last Name:MCRAE
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 1:911 N GOLIAD ST
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-2230
Mailing Address - Country:US
Mailing Address - Phone:469-458-9021
Mailing Address - Fax:866-693-6509
Practice Address - Street 1:911 N GOLIAD ST
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-2230
Practice Address - Country:US
Practice Address - Phone:469-458-9021
Practice Address - Fax:866-693-6509
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-21-163537106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician