Provider Demographics
NPI:1841833712
Name:WEBER, MADISON RENEE (RS)
Entity type:Individual
Prefix:MS
First Name:MADISON
Middle Name:RENEE
Last Name:WEBER
Suffix:
Gender:F
Credentials:RS
Other - Prefix:
Other - First Name:MADDIE
Other - Middle Name:RENEE
Other - Last Name:WEBER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2023 BETHEL ST NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-3377
Mailing Address - Country:US
Mailing Address - Phone:360-867-8510
Mailing Address - Fax:
Practice Address - Street 1:3436 MARY ELDER RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5050
Practice Address - Country:US
Practice Address - Phone:360-528-2590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60972061174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA110043589004Medicaid