Provider Demographics
NPI:1497435598
Name:KANITZ, MADISON ELIZABETH
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:ELIZABETH
Last Name:KANITZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:ELIZABETH
Other - Last Name:LOPPNOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:21370 CAMBRIDGE CIRCLE LOWER
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-3205
Mailing Address - Country:US
Mailing Address - Phone:404-804-6572
Mailing Address - Fax:
Practice Address - Street 1:200 N PATRICK BLVD STE 250
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-5883
Practice Address - Country:US
Practice Address - Phone:888-754-0398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty