Provider Demographics
NPI:1609468461
Name:WYATT, MADISON TAYLOR
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:TAYLOR
Last Name:WYATT
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 1:15750 SW OREGON ST APT 203
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-9622
Mailing Address - Country:US
Mailing Address - Phone:949-310-5060
Mailing Address - Fax:
Practice Address - Street 1:7475 SW OLESON RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-7474
Practice Address - Country:US
Practice Address - Phone:971-804-0907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-03
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
ORB-10244325103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician