Provider Demographics
NPI:1407224603
Name:MADGETT, BILLY
Entity Type:Individual
Prefix:
First Name:BILLY
Middle Name:
Last Name:MADGETT
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 1:4747 W 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46406-2821
Mailing Address - Country:US
Mailing Address - Phone:219-240-6015
Mailing Address - Fax:
Practice Address - Street 1:4747 W 24TH AVE
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46406-2821
Practice Address - Country:US
Practice Address - Phone:219-240-6015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-04
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness