Provider Demographics
NPI:1558954271
Name:MITOLA, MADISON MARY
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:MARY
Last Name:MITOLA
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MADISON
Other - Middle Name:MARY
Other - Last Name:MITOLA-ESER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMSW
Mailing Address - Street 1:467 COOPERS HAWK DR
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-8208
Mailing Address - Country:US
Mailing Address - Phone:631-796-6249
Mailing Address - Fax:
Practice Address - Street 1:467 COOPERS HAWK DR
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-8208
Practice Address - Country:US
Practice Address - Phone:631-796-6249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-12
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14004104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker