Provider Demographics
NPI:1356154967
Name:STREET, MADISON
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:STREET
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 1:1383 E SOUTHVIEW LN
Mailing Address - Street 2:
Mailing Address - City:PAOLI
Mailing Address - State:IN
Mailing Address - Zip Code:47454-9477
Mailing Address - Country:US
Mailing Address - Phone:812-865-0729
Mailing Address - Fax:
Practice Address - Street 1:1441 S FENBROOK LN # 400D
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-4176
Practice Address - Country:US
Practice Address - Phone:812-322-4494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-28
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN46004555A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist