Provider Demographics
NPI:1275151417
Name:PASSMORE, MADISON (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:PASSMORE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17520 OLD JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-3903
Mailing Address - Country:US
Mailing Address - Phone:225-300-6710
Mailing Address - Fax:
Practice Address - Street 1:17520 OLD JEFFERSON HWY
Practice Address - Street 2:
Practice Address - City:PRAIRIEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70769-3903
Practice Address - Country:US
Practice Address - Phone:225-300-6710
Practice Address - Fax:225-300-6712
Is Sole Proprietor?:No
Enumeration Date:2020-07-13
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS4673235Z00000X
LA8918235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist