Provider Demographics
NPI:1134897762
Name:VICENDESE, MADISON LAURYNN
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:LAURYNN
Last Name:VICENDESE
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 1:1 GLOUCESTER RD APT 1902
Mailing Address - Street 2:
Mailing Address - City:HILTON HEAD ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29928-0809
Mailing Address - Country:US
Mailing Address - Phone:443-896-6292
Mailing Address - Fax:
Practice Address - Street 1:1536 FORDING ISLAND RD
Practice Address - Street 2:
Practice Address - City:HILTON HEAD ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29926-1120
Practice Address - Country:US
Practice Address - Phone:843-837-2080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7758235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist