Provider Demographics
NPI:1215218615
Name:MADISON, MICHELLE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:MADISON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701
Mailing Address - Country:US
Mailing Address - Phone:516-264-0058
Mailing Address - Fax:
Practice Address - Street 1:191 BROADWAY
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-2790
Practice Address - Country:US
Practice Address - Phone:631-264-0058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-30
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY083215-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical