Provider Demographics
NPI:1336721968
Name:FRADESTIN, MADLYE YOUNIE
Entity Type:Individual
Prefix:
First Name:MADLYE
Middle Name:YOUNIE
Last Name:FRADESTIN
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 1:4723 SABLE PINE CIR APT D2
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33417-2797
Mailing Address - Country:US
Mailing Address - Phone:561-507-8643
Mailing Address - Fax:
Practice Address - Street 1:2979 PGA BLVD STE 200
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-3002
Practice Address - Country:US
Practice Address - Phone:561-260-5900
Practice Address - Fax:561-513-8211
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-23
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician