Provider Demographics
NPI:1346632544
Name:COKE, MADIA J
Entity Type:Individual
Prefix:MISS
First Name:MADIA
Middle Name:J
Last Name:COKE
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 1:2060 TURTLE CREEK WAY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-6944
Mailing Address - Country:US
Mailing Address - Phone:470-207-5388
Mailing Address - Fax:
Practice Address - Street 1:2060 TURTLE CREEK WAY
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-6944
Practice Address - Country:US
Practice Address - Phone:470-207-5388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-24
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1125860103TS0200X
NY43844101103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool