Provider Demographics
NPI:1558933143
Name:DIEDERICH, MADISON BROOKE (LMSW)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:BROOKE
Last Name:DIEDERICH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1558 HAYES DR
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502-5068
Mailing Address - Country:US
Mailing Address - Phone:785-587-4300
Mailing Address - Fax:
Practice Address - Street 1:1558 HAYES DR
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-5068
Practice Address - Country:US
Practice Address - Phone:785-587-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS12157104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker