Provider Demographics
NPI:1639536469
Name:MADISON, MIESHAN
Entity Type:Individual
Prefix:
First Name:MIESHAN
Middle Name:
Last Name:MADISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1541 HANGING MOSS LN
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70056-7794
Mailing Address - Country:US
Mailing Address - Phone:504-307-1100
Mailing Address - Fax:
Practice Address - Street 1:4700 WICHERS DR STE 2-5
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3041
Practice Address - Country:US
Practice Address - Phone:504-407-0709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-25
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health