Provider Demographics
NPI:1750156097
Name:PHILLIPS, MADISON GRACE
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:GRACE
Last Name:PHILLIPS
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 1:320 N 21ST AVE
Mailing Address - Street 2:
Mailing Address - City:BEECH GROVE
Mailing Address - State:IN
Mailing Address - Zip Code:46107-1026
Mailing Address - Country:US
Mailing Address - Phone:810-404-3538
Mailing Address - Fax:
Practice Address - Street 1:9905 FALL CREEK RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-4804
Practice Address - Country:US
Practice Address - Phone:317-813-4690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-16
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-20-147549106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician