Provider Demographics
NPI:1700235801
Name:KENWORTHY, MADISON
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:KENWORTHY
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 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:885-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:1026 PATHFINDER WAY
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3216
Practice Address - Country:US
Practice Address - Phone:855-324-0885
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2016-06-09
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL15-10564103K00000X
FLRBT-15-10564106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL15-10564OtherRBT