Provider Demographics
NPI:1174502348
Name:MADISON, DEANNA J (LPC, LPA)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:J
Last Name:MADISON
Suffix:
Gender:F
Credentials:LPC, LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 58362
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28305-8362
Mailing Address - Country:US
Mailing Address - Phone:910-483-3373
Mailing Address - Fax:910-426-3921
Practice Address - Street 1:103 FOUNTAINHEAD LN
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-5462
Practice Address - Country:US
Practice Address - Phone:910-483-3373
Practice Address - Fax:910-426-3921
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3207101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC130RKOtherBLUE CROSS BLUE SHIELD
NC196506OtherCOMPSYCH
NC6107085Medicaid