Provider Demographics
NPI:1912897570
Name:SIEBERT, MADISON LANE
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:LANE
Last Name:SIEBERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:LANE
Other - Last Name:MALLADY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:458 MELODY LN
Mailing Address - Street 2:
Mailing Address - City:CUBA
Mailing Address - State:MO
Mailing Address - Zip Code:65453-8197
Mailing Address - Country:US
Mailing Address - Phone:573-241-2059
Mailing Address - Fax:
Practice Address - Street 1:910 W 14TH ST STE 230
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-7003
Practice Address - Country:US
Practice Address - Phone:636-283-3022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-07
Last Update Date:2025-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOIA-0008084182103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst