Provider Demographics
NPI:1326746496
Name:KNOWLTON, MADISON RENEE (LLMSW)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:RENEE
Last Name:KNOWLTON
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 BAYBERRY POINTE DR NW APT F
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49534-4643
Mailing Address - Country:US
Mailing Address - Phone:760-884-7539
Mailing Address - Fax:
Practice Address - Street 1:1346 BALDWIN ST
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-8937
Practice Address - Country:US
Practice Address - Phone:616-765-8585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-20
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical