Provider Demographics
NPI:1629695861
Name:RISSE, MADELINE ROSE (RBT)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:ROSE
Last Name:RISSE
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3609 PALM CROSSING DR UNIT 201
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-4996
Mailing Address - Country:US
Mailing Address - Phone:706-201-9039
Mailing Address - Fax:
Practice Address - Street 1:7777 131ST ST STE 7
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33776-4015
Practice Address - Country:US
Practice Address - Phone:727-224-5301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-04
Last Update Date:2020-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician