Basic Information
| Provider Information | |||||||||
| NPI: | 1134696164 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAMBACH | ||||||||
| FirstName: | MADALYN | ||||||||
| MiddleName: | PAIGE | ||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 E NASA BLVD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329011900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3213726813 | ||||||||
| FaxNumber: | 3217656434 | ||||||||
| Practice Location | |||||||||
| Address1: | 331 LANDRUM PL | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370436329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315531395 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2018 | ||||||||
| LastUpdateDate: | 03/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 530 | TN | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.