Provider Demographics
NPI:1649797309
Name:CRISWELL, MADISON PRYOR (SLP)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:PRYOR
Last Name:CRISWELL
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8478 RAINBOW BRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22153-2513
Mailing Address - Country:US
Mailing Address - Phone:901-484-8596
Mailing Address - Fax:
Practice Address - Street 1:8478 RAINBOW BRIDGE LN
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22153-2513
Practice Address - Country:US
Practice Address - Phone:901-484-8596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-24
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202009565235Z00000X
MO2019045744235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist