Provider Demographics
NPI:1174254619
Name:KOSTUR, MADALYN MARIE (LCSWA)
Entity Type:Individual
Prefix:
First Name:MADALYN
Middle Name:MARIE
Last Name:KOSTUR
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 EAST BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5156
Mailing Address - Country:US
Mailing Address - Phone:704-980-3082
Mailing Address - Fax:704-980-3082
Practice Address - Street 1:700 EAST BLVD STE 1
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5156
Practice Address - Country:US
Practice Address - Phone:704-980-3082
Practice Address - Fax:704-980-3082
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0176761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical