Provider Demographics
NPI:1134604010
Name:MADDEN, MISTY MICHELE (BCBA)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:MICHELE
Last Name:MADDEN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:MICHELE
Other - Last Name:SHEPPARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2007 WINDROE DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042-5251
Mailing Address - Country:US
Mailing Address - Phone:530-933-9892
Mailing Address - Fax:
Practice Address - Street 1:2007 WINDROE DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042-5251
Practice Address - Country:US
Practice Address - Phone:530-933-9892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-26
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF2306223247200000X
TN1050103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other