Provider Demographics
NPI:1417438011
Name:WESTERHOLD, MADISON SPEARS
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:SPEARS
Last Name:WESTERHOLD
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:PO BOX 11231
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-1231
Mailing Address - Country:US
Mailing Address - Phone:720-448-6227
Mailing Address - Fax:
Practice Address - Street 1:310 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8636
Practice Address - Country:US
Practice Address - Phone:720-448-6227
Practice Address - Fax:307-333-0513
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYRBT-18-63328106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician