Provider Demographics
NPI:1477280246
Name:FANTON, MADELINE RAE (MT-BC)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:RAE
Last Name:FANTON
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11520 S 39TH ST APT 15
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68123-1278
Mailing Address - Country:US
Mailing Address - Phone:402-580-0706
Mailing Address - Fax:
Practice Address - Street 1:11520 S 39TH ST APT 15
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68123-1278
Practice Address - Country:US
Practice Address - Phone:402-580-0706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist