Provider Demographics
NPI:1730642315
Name:HANAN, MADALYN (RBT)
Entity Type:Individual
Prefix:
First Name:MADALYN
Middle Name:
Last Name:HANAN
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 1:1105 W RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-1322
Mailing Address - Country:US
Mailing Address - Phone:605-271-2690
Mailing Address - Fax:605-271-3956
Practice Address - Street 1:3721 23RD ST S # 201
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-6198
Practice Address - Country:US
Practice Address - Phone:605-271-2690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-10
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNRBT-21-180887106S00000X
373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist