Provider Demographics
NPI:1912578873
Name:PEATH, MADELYN GRACE
Entity Type:Individual
Prefix:
First Name:MADELYN
Middle Name:GRACE
Last Name:PEATH
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 1:108 MAY CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-3590
Mailing Address - Country:US
Mailing Address - Phone:716-517-6568
Mailing Address - Fax:
Practice Address - Street 1:51 PLAZA DR STE D
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540-5054
Practice Address - Country:US
Practice Address - Phone:910-939-9986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-01
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician