Provider Demographics
NPI:1801237961
Name:ANDREU, MADISON BRIANNE
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:BRIANNE
Last Name:ANDREU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:BRIANNE
Other - Last Name:STANEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:145 E EDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-4014
Mailing Address - Country:US
Mailing Address - Phone:863-619-2809
Mailing Address - Fax:
Practice Address - Street 1:145 E EDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-4014
Practice Address - Country:US
Practice Address - Phone:863-619-2809
Practice Address - Fax:863-644-9590
Is Sole Proprietor?:No
Enumeration Date:2013-07-17
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
FL1-16-24426103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other