Provider Demographics
NPI:1376017426
Name:HERSLEBS, MADISAN MAE (MS, CF-SLP)
Entity Type:Individual
Prefix:
First Name:MADISAN
Middle Name:MAE
Last Name:HERSLEBS
Suffix:
Gender:F
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 SHEFFIELD WAY
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-1602
Mailing Address - Country:US
Mailing Address - Phone:770-823-0954
Mailing Address - Fax:
Practice Address - Street 1:5980 RADIO STATION RD
Practice Address - Street 2:
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646-3337
Practice Address - Country:US
Practice Address - Phone:770-823-0954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-11
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist