Provider Demographics
NPI:1659988160
Name:DYKES-WELLER, MADISON
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:DYKES-WELLER
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 1:537 DELTONA BLVD
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32725-8017
Mailing Address - Country:US
Mailing Address - Phone:904-878-8683
Mailing Address - Fax:386-200-5752
Practice Address - Street 1:440 S MELLONVILLE AVE
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-2264
Practice Address - Country:US
Practice Address - Phone:904-878-8683
Practice Address - Fax:386-200-5752
Is Sole Proprietor?:No
Enumeration Date:2020-09-29
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician