Provider Demographics
NPI:1770173155
Name:GERDOM, MADISON LYNN
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:LYNN
Last Name:GERDOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:LYNN
Other - Last Name:BARRETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3201 W CHARLOTTE ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-4323
Mailing Address - Country:US
Mailing Address - Phone:970-397-5263
Mailing Address - Fax:
Practice Address - Street 1:308 N ASPEN AVE
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-2205
Practice Address - Country:US
Practice Address - Phone:539-777-0940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician