Provider Demographics
NPI:1437666880
Name:MADIGAN, MARK JOHN
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JOHN
Last Name:MADIGAN
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 1:1759 STATE HIGHWAY FF
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-8365
Mailing Address - Country:US
Mailing Address - Phone:573-225-0891
Mailing Address - Fax:
Practice Address - Street 1:760 PLANTATION BLVD
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-5736
Practice Address - Country:US
Practice Address - Phone:573-471-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017042915101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional