Provider Demographics
NPI:1215392659
Name:BERESFORD, MADISON
Entity Type:Individual
Prefix:DR
First Name:MADISON
Middle Name:
Last Name:BERESFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 EXCHANGE DR
Mailing Address - Street 2:SUITE 101B
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-6230
Mailing Address - Country:US
Mailing Address - Phone:224-286-4673
Mailing Address - Fax:
Practice Address - Street 1:265 EXCHANGE DR
Practice Address - Street 2:SUITE 101B
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-6230
Practice Address - Country:US
Practice Address - Phone:224-286-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-30
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health