Provider Demographics
NPI:1952873119
Name:MORITZ, MADISON BAIN (BCBA)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:BAIN
Last Name:MORITZ
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4747 N MILL CT
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46140-8005
Mailing Address - Country:US
Mailing Address - Phone:317-441-0249
Mailing Address - Fax:
Practice Address - Street 1:8328 MASTERS RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-1538
Practice Address - Country:US
Practice Address - Phone:317-436-7080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-27
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-18-33103103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst