Provider Demographics
NPI:1841799889
Name:SUTTON, MADASYN
Entity Type:Individual
Prefix:
First Name:MADASYN
Middle Name:
Last Name:SUTTON
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 1:1100 HAXTON DR UNIT 115
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-6213
Mailing Address - Country:US
Mailing Address - Phone:970-305-8642
Mailing Address - Fax:
Practice Address - Street 1:1100 HAXTON DR UNIT 115
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-6213
Practice Address - Country:US
Practice Address - Phone:970-305-8642
Practice Address - Fax:970-310-4555
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY109318-253106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician