Provider Demographics
NPI:1255086021
Name:BREWER, MADISON MARYROSE
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:MARYROSE
Last Name:BREWER
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 1:2111 HARRISONVILLE AVE APT B
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-8073
Mailing Address - Country:US
Mailing Address - Phone:740-727-1120
Mailing Address - Fax:
Practice Address - Street 1:1008 FAIRLANE DR
Practice Address - Street 2:
Practice Address - City:VANCEBURG
Practice Address - State:KY
Practice Address - Zip Code:41179-5403
Practice Address - Country:US
Practice Address - Phone:740-727-1120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-19
Last Update Date:2022-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRBT-21-191059106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty