Provider Demographics
NPI:1306361639
Name:MADISON, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:MADISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 BIG LOOK TRL
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-2822
Mailing Address - Country:US
Mailing Address - Phone:609-224-4779
Mailing Address - Fax:
Practice Address - Street 1:181 UNION ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901-1311
Practice Address - Country:US
Practice Address - Phone:781-244-1950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-08
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
00275308101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health