Provider Demographics
NPI:1467436790
Name:VAN EPP, MADELAINE E (LMFT)
Entity Type:Individual
Prefix:
First Name:MADELAINE
Middle Name:E
Last Name:VAN EPP
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 BRADBURY DR SE
Mailing Address - Street 2:SUITE 2222
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4374
Mailing Address - Country:US
Mailing Address - Phone:505-272-2312
Mailing Address - Fax:505-272-8060
Practice Address - Street 1:2450 ALAMO AVE SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-3204
Practice Address - Country:US
Practice Address - Phone:505-925-2400
Practice Address - Fax:505-925-2411
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM006970106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM57126577Medicaid