Provider Demographics
NPI:1003164286
Name:MADSEN-HESKIN, MARY (MA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MADSEN-HESKIN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 DUNHAM RD STE 2A
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-1498
Mailing Address - Country:US
Mailing Address - Phone:224-805-0600
Mailing Address - Fax:331-422-2905
Practice Address - Street 1:475 DUNHAM RD STE 2A
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-1498
Practice Address - Country:US
Practice Address - Phone:224-805-0600
Practice Address - Fax:331-422-2905
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-20
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180004564101Y00000X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health