Provider Demographics
NPI:1639950652
Name:GOSKE, MADISON
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:GOSKE
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:PO BOX 708
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44473-0708
Mailing Address - Country:US
Mailing Address - Phone:330-506-5635
Mailing Address - Fax:
Practice Address - Street 1:8700 SUITE 3, EAST MARKET STREET
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484
Practice Address - Country:US
Practice Address - Phone:330-506-5635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-06
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.23042521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical