Provider Demographics
NPI:1790433993
Name:LERCH, MADISON LENEE (RBT)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:LENEE
Last Name:LERCH
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 PINTAIL LN APT 302
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33896-7049
Mailing Address - Country:US
Mailing Address - Phone:321-405-9227
Mailing Address - Fax:
Practice Address - Street 1:501 E KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33602-5237
Practice Address - Country:US
Practice Address - Phone:352-646-2638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-16
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-206581106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLNAMedicaid