Provider Demographics
NPI:1619672813
Name:UDY, MADISON NICOLE (BSHA)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:NICOLE
Last Name:UDY
Suffix:
Gender:F
Credentials:BSHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 S GRAND AVE W
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-3550
Mailing Address - Country:US
Mailing Address - Phone:801-592-5375
Mailing Address - Fax:
Practice Address - Street 1:1011 S GRAND AVE W
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-3550
Practice Address - Country:US
Practice Address - Phone:801-592-5375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-05
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
No253Z00000XAgenciesIn Home Supportive Care