Provider Demographics
NPI:1467058800
Name:MADONNA, MATHEW JOHN (PSYAD, LMHC)
Entity Type:Individual
Prefix:
First Name:MATHEW
Middle Name:JOHN
Last Name:MADONNA
Suffix:
Gender:M
Credentials:PSYAD, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 ADAMS RD
Mailing Address - Street 2:
Mailing Address - City:ATHOL
Mailing Address - State:MA
Mailing Address - Zip Code:01331-9751
Mailing Address - Country:US
Mailing Address - Phone:774-641-6228
Mailing Address - Fax:
Practice Address - Street 1:59 ADAMS RD
Practice Address - Street 2:
Practice Address - City:ATHOL
Practice Address - State:MA
Practice Address - Zip Code:01331-9751
Practice Address - Country:US
Practice Address - Phone:774-641-6228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9171101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health