Provider Demographics
NPI:1235822263
Name:LAVALLE, MADISON (SLP)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:LAVALLE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 SW REGENCY PKWY STE 5
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-7488
Mailing Address - Country:US
Mailing Address - Phone:479-252-3321
Mailing Address - Fax:479-658-2257
Practice Address - Street 1:3201 SW REGENCY PKWY STE 5
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-7488
Practice Address - Country:US
Practice Address - Phone:479-252-3321
Practice Address - Fax:479-658-2257
Is Sole Proprietor?:No
Enumeration Date:2023-05-26
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR202209235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist