Provider Demographics
NPI:1952561466
Name:MADISON, BENITA (SLP)
Entity Type:Individual
Prefix:
First Name:BENITA
Middle Name:
Last Name:MADISON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2898 SUMMIT DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-6247
Mailing Address - Country:US
Mailing Address - Phone:404-664-2208
Mailing Address - Fax:
Practice Address - Street 1:3056 ANVIL BLOCK RD STE 118
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-2864
Practice Address - Country:US
Practice Address - Phone:404-366-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006366235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA049255437OtherDRIVER'S LICENSE