Provider Demographics
NPI:1376017426
Name:HERSLEBS, MADISAN MAE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MADISAN
Middle Name:MAE
Last Name:HERSLEBS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 WIND FOREST CT
Mailing Address - Street 2:
Mailing Address - City:CLARKESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30523
Mailing Address - Country:US
Mailing Address - Phone:770-823-0954
Mailing Address - Fax:
Practice Address - Street 1:273 QUILLIAN STREET
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:GA
Practice Address - Zip Code:30528
Practice Address - Country:US
Practice Address - Phone:706-865-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-11
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP013246235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist