Provider Demographics
NPI:1508392341
Name:EMANUEL, MADELEINE
Entity Type:Individual
Prefix:
First Name:MADELEINE
Middle Name:
Last Name:EMANUEL
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 1:3182 GULF BREEZE PKWY
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32563-3248
Mailing Address - Country:US
Mailing Address - Phone:800-676-5130
Mailing Address - Fax:888-958-5753
Practice Address - Street 1:2288 BLUE WATER BLVD STE 310
Practice Address - Street 2:
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-3301
Practice Address - Country:US
Practice Address - Phone:410-630-6936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
MDRBT-16-23682106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician