Provider Demographics
NPI:1417948993
Name:ALTABE, MADELINE (PHD)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:ALTABE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7747 MITCHELL BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-4725
Mailing Address - Country:US
Mailing Address - Phone:404-941-6402
Mailing Address - Fax:
Practice Address - Street 1:7747 MITCHELL BLVD STE B
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-4725
Practice Address - Country:US
Practice Address - Phone:404-941-6402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4848103TA0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Provider Identifiers
StateIdentifier IDID TypeIssuer
59354OtherBC/BS FLORIDA
59354OtherBC/BS FLORIDA