Provider Demographics
NPI:1417631896
Name:BEAR, MADISON
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:BEAR
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:W8053 WHITETAIL DR
Mailing Address - Street 2:
Mailing Address - City:PARDEEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53954-9588
Mailing Address - Country:US
Mailing Address - Phone:608-617-4383
Mailing Address - Fax:
Practice Address - Street 1:1508 NEW PINERY RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-1312
Practice Address - Country:US
Practice Address - Phone:608-745-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7461-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health