Provider Demographics
NPI:1407469091
Name:ANNIS, MADISON (BCBA)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:ANNIS
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19107 MANGIERI ST
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-4559
Mailing Address - Country:US
Mailing Address - Phone:603-793-3118
Mailing Address - Fax:
Practice Address - Street 1:19107 MANGIERI ST
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293-4559
Practice Address - Country:US
Practice Address - Phone:603-793-3118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-20-42491103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111601500Medicaid
NH3125416Medicaid