Provider Demographics
NPI:1639924293
Name:PROUGH, MADISON DANAE
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:DANAE
Last Name:PROUGH
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 1:2531 E 32ND ST
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-3129
Mailing Address - Country:US
Mailing Address - Phone:417-988-6253
Mailing Address - Fax:
Practice Address - Street 1:2531 E 32ND ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3129
Practice Address - Country:US
Practice Address - Phone:417-988-6253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-18
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician