Provider Demographics
NPI:1629731740
Name:MADISON, SHARDAE (RBT)
Entity Type:Individual
Prefix:MS
First Name:SHARDAE
Middle Name:
Last Name:MADISON
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 1:1240 S NOVA RD APT 119
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-5886
Mailing Address - Country:US
Mailing Address - Phone:248-935-8231
Mailing Address - Fax:
Practice Address - Street 1:1240 S NOVA RD APT 119
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-5886
Practice Address - Country:US
Practice Address - Phone:248-935-8231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-15
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21151047106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician