Provider Demographics
NPI:1629514757
Name:MILLER, MADISON
Entity Type:Individual
Prefix:MRS
First Name:MADISON
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MADISON
Other - Middle Name:
Other - Last Name:COLLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3552 FM 1092 RD
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-2203
Mailing Address - Country:US
Mailing Address - Phone:346-368-4412
Mailing Address - Fax:855-742-3123
Practice Address - Street 1:3552 FM 1092 RD
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-2203
Practice Address - Country:US
Practice Address - Phone:346-368-4412
Practice Address - Fax:855-742-3123
Is Sole Proprietor?:No
Enumeration Date:2017-01-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2168103K00000X
SC1-16-24628103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst