Provider Demographics
NPI:1730617747
Name:FEHRENBACHER, MADISON TAYLOR (LMP)
Entity type:Individual
Prefix:MS
First Name:MADISON
Middle Name:TAYLOR
Last Name:FEHRENBACHER
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7313 164TH ST E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98375-7239
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6615 6TH AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406-2027
Practice Address - Country:US
Practice Address - Phone:253-683-4277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-03
Last Update Date:2017-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60752567225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty