Provider Demographics
NPI:1447539960
Name:WEST, MADISON TAYLOR
Entity type:Individual
Prefix:MRS
First Name:MADISON
Middle Name:TAYLOR
Last Name:WEST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:TAYLOR
Other - Last Name:FENTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1690 STONE VILLAGE LN NW STE 622
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-7777
Mailing Address - Country:US
Mailing Address - Phone:678-740-3578
Mailing Address - Fax:
Practice Address - Street 1:1690 STONE VILLAGE LN NW STE 622
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-7777
Practice Address - Country:US
Practice Address - Phone:678-740-3578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-15
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT001316106H00000X, 106H00000X
CA53935106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist