Provider Demographics
NPI:1215628136
Name:FIORENTINO, MADISON (ABA)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:FIORENTINO
Suffix:
Gender:U
Credentials:ABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18765 SW BOONES FERRY RD STE 100
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062
Mailing Address - Country:US
Mailing Address - Phone:503-612-1000
Mailing Address - Fax:
Practice Address - Street 1:18765 SW BOONES FERRY RD STE 100
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062
Practice Address - Country:US
Practice Address - Phone:503-612-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-19
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORABA-IN-10232926106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician