Provider Demographics
NPI:1679075030
Name:LEE, MADISON (BCBA)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:LEE
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 1:4268 W HADLEY WOOD LN
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-1433
Mailing Address - Country:US
Mailing Address - Phone:858-245-8524
Mailing Address - Fax:
Practice Address - Street 1:14 WESTPORT AVE
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-3915
Practice Address - Country:US
Practice Address - Phone:858-245-8524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-01
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1-19-39434103K00000X
TX3684103K00000X
CT1587103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst