Provider Demographics
NPI:1619344496
Name:MADAMBA, HENRY
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:
Last Name:MADAMBA
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 1:750 PASADENA DR
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:08225-1169
Mailing Address - Country:US
Mailing Address - Phone:609-287-0697
Mailing Address - Fax:
Practice Address - Street 1:222 NEW RD STE 405
Practice Address - Street 2:
Practice Address - City:LINWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08221-1283
Practice Address - Country:US
Practice Address - Phone:609-289-5354
Practice Address - Fax:609-266-0459
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-27
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00096500103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling