Provider Demographics
NPI:1235937392
Name:GERLACH, MADISON
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:GERLACH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-3549
Mailing Address - Country:US
Mailing Address - Phone:317-572-8793
Mailing Address - Fax:
Practice Address - Street 1:1325 W 4TH ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-3549
Practice Address - Country:US
Practice Address - Phone:317-572-8793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-05
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician