Provider Demographics
NPI:1417918285
Name:PARKS, MADELON JEAN (PHD)
Entity Type:Individual
Prefix:
First Name:MADELON
Middle Name:JEAN
Last Name:PARKS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:FLETCHER
Mailing Address - State:NC
Mailing Address - Zip Code:28732-9734
Mailing Address - Country:US
Mailing Address - Phone:828-329-8306
Mailing Address - Fax:828-258-3831
Practice Address - Street 1:455 CONCORD RD
Practice Address - Street 2:
Practice Address - City:FLETCHER
Practice Address - State:NC
Practice Address - Zip Code:28732-9734
Practice Address - Country:US
Practice Address - Phone:828-329-8306
Practice Address - Fax:828-258-3831
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2915103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC108059OtherVALUE OPTIONS
NCU02489965OtherCIGNA BEHAVIORAL
NC6000594Medicaid
NCC8053OtherMEDCOST
NC045YFOtherBCBSNC
NC108059OtherVALUE OPTIONS