Provider Demographics
NPI:1265139521
Name:CONWELL, MADISON LOGAN
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:LOGAN
Last Name:CONWELL
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 1:1701 N GREEN VALLEY PKWY STE 9B
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-5991
Mailing Address - Country:US
Mailing Address - Phone:725-333-4005
Mailing Address - Fax:
Practice Address - Street 1:1701 N GREEN VALLEY PKWY STE 9B
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-5991
Practice Address - Country:US
Practice Address - Phone:725-333-4005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-07
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician