Provider Demographics
NPI:1922617455
Name:CHASE, MADISON SCOTT (SLP)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:SCOTT
Last Name:CHASE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 11TH ST NE APT 1618
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-4380
Mailing Address - Country:US
Mailing Address - Phone:908-489-5746
Mailing Address - Fax:
Practice Address - Street 1:1130 SENOIA RD STE A1
Practice Address - Street 2:
Practice Address - City:TYRONE
Practice Address - State:GA
Practice Address - Zip Code:30290-1640
Practice Address - Country:US
Practice Address - Phone:678-632-6765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-30
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP01135235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist