Provider Demographics
NPI:1376365908
Name:ROSTER, MADDELYNN OLIVIA
Entity type:Individual
Prefix:
First Name:MADDELYNN
Middle Name:OLIVIA
Last Name:ROSTER
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 1:1050 S ACADEMY BLVD SUITE 140
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910
Mailing Address - Country:US
Mailing Address - Phone:888-754-0389
Mailing Address - Fax:
Practice Address - Street 1:1050 S ACADEMY BLVD SUITE 140
Practice Address - Street 2:
Practice Address - City:COLORADO SPGS
Practice Address - State:CO
Practice Address - Zip Code:80910
Practice Address - Country:US
Practice Address - Phone:888-754-0398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-25
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician