Provider Demographics
NPI:1679312714
Name:YUDT, MADISON SYDNEY
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:SYDNEY
Last Name:YUDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:
Other - Last Name:BURTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:815 LEMASTER AVE
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23669-1210
Mailing Address - Country:US
Mailing Address - Phone:814-812-4647
Mailing Address - Fax:
Practice Address - Street 1:800 E CITY HALL AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510-2723
Practice Address - Country:US
Practice Address - Phone:757-670-3945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-20
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAPPS-0608432103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool