Provider Demographics
NPI:1376227702
Name:LOCKAMY, MADISON TAYLOR
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:TAYLOR
Last Name:LOCKAMY
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 1:140B PURCELLVILLE GATEWAY DR # 536
Mailing Address - Street 2:
Mailing Address - City:PURCELLVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20132-3485
Mailing Address - Country:US
Mailing Address - Phone:703-577-4061
Mailing Address - Fax:
Practice Address - Street 1:3014 COLVIN ST # 1A
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-5031
Practice Address - Country:US
Practice Address - Phone:703-577-4061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704016243101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health