Provider Demographics
NPI:1093372484
Name:MADLOCK & ASSOCIATES
Entity Type:Organization
Organization Name:MADLOCK & ASSOCIATES
Other - Org Name:MADLOCK & ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:FELICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MADLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:773-369-6545
Mailing Address - Street 1:430 E 162ND ST # 109
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-2258
Mailing Address - Country:US
Mailing Address - Phone:773-369-6545
Mailing Address - Fax:
Practice Address - Street 1:10336 S WESTERN AVE STE 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-2407
Practice Address - Country:US
Practice Address - Phone:773-369-6545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-21
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1093372484Medicaid