Provider Demographics
NPI:1811539281
Name:RUSSELL, MADISON RAGAN HOOVER (MS, BCBA)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:RAGAN HOOVER
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:RAGAN
Other - Last Name:HOOVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 SHARON TRL
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-1301
Mailing Address - Country:US
Mailing Address - Phone:404-808-9945
Mailing Address - Fax:
Practice Address - Street 1:102 MARY ALICE PARK RD STE 304
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2683
Practice Address - Country:US
Practice Address - Phone:443-414-1843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-17
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
GA1-24-73418103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician