Provider Demographics
NPI:1053896688
Name:MADISON, PAMELA
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:MADISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2224 WHARF DR APT 1503
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-5354
Mailing Address - Country:US
Mailing Address - Phone:630-689-6224
Mailing Address - Fax:
Practice Address - Street 1:2224 WHARF DR APT 1503
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-5354
Practice Address - Country:US
Practice Address - Phone:630-689-6224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-28
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency