Provider Demographics
NPI:1174221006
Name:GAULT, MADILYN ROSE
Entity type:Individual
Prefix:
First Name:MADILYN
Middle Name:ROSE
Last Name:GAULT
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 1:1451 LAKEMIST LN
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-5378
Mailing Address - Country:US
Mailing Address - Phone:407-818-2406
Mailing Address - Fax:
Practice Address - Street 1:1451 LAKEMIST LN
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-5378
Practice Address - Country:US
Practice Address - Phone:407-818-2406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-20
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X
252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist