Provider Demographics
NPI:1659081180
Name:MADISON, KASSIANNA G
Entity Type:Individual
Prefix:
First Name:KASSIANNA
Middle Name:G
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 1:459 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4505
Mailing Address - Country:US
Mailing Address - Phone:920-929-3500
Mailing Address - Fax:920-929-3129
Practice Address - Street 1:459 E 1ST ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4505
Practice Address - Country:US
Practice Address - Phone:920-929-3500
Practice Address - Fax:920-929-3129
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-23
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor