Provider Demographics
NPI:1215598206
Name:SCHALLER, MADISON NICOLE (LBA)
Entity Type:Individual
Prefix:MS
First Name:MADISON
Middle Name:NICOLE
Last Name:SCHALLER
Suffix:
Gender:F
Credentials:LBA
Other - Prefix:MS
Other - First Name:MADISON
Other - Middle Name:
Other - Last Name:SCHALLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 11077
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27532-5018
Mailing Address - Country:US
Mailing Address - Phone:919-947-4015
Mailing Address - Fax:855-492-1625
Practice Address - Street 1:1031 WH SMITH BLVD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834
Practice Address - Country:US
Practice Address - Phone:252-493-6252
Practice Address - Fax:855-492-1625
Is Sole Proprietor?:No
Enumeration Date:2019-06-21
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC872103K00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No171M00000XOther Service ProvidersCase Manager/Care Coordinator