Provider Demographics
NPI:1457858136
Name:MADLOCK, CONNIE O
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:O
Last Name:MADLOCK
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 1:3707 N RICHARDS ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1673
Mailing Address - Country:US
Mailing Address - Phone:414-967-7006
Mailing Address - Fax:414-967-7020
Practice Address - Street 1:3707 N RICHARDS ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-1673
Practice Address - Country:US
Practice Address - Phone:414-967-7006
Practice Address - Fax:414-967-7020
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-10
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16826-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty