Provider Demographics
NPI:1275171761
Name:WALTH, MADISON
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:WALTH
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 1:112 TOMBSTONE CT
Mailing Address - Street 2:
Mailing Address - City:ALTO
Mailing Address - State:NM
Mailing Address - Zip Code:88312-9636
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:112 TOMBSTONE CT
Practice Address - Street 2:
Practice Address - City:ALTO
Practice Address - State:NM
Practice Address - Zip Code:88312-9636
Practice Address - Country:US
Practice Address - Phone:575-937-9197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-15
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician