Provider Demographics
NPI:1043994577
Name:VANDERLUGT, MADISON
Entity Type:Individual
Prefix:MRS
First Name:MADISON
Middle Name:
Last Name:VANDERLUGT
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 1:2805 HICKS RD
Mailing Address - Street 2:
Mailing Address - City:TURBEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29162-9106
Mailing Address - Country:US
Mailing Address - Phone:843-598-5397
Mailing Address - Fax:
Practice Address - Street 1:14 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-3502
Practice Address - Country:US
Practice Address - Phone:803-435-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
SC8803101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)