Provider Demographics
NPI:1710409024
Name:MADRAKE, MARY (PSYD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MADRAKE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 W CALENDAR AVE APT 3B
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-2029
Mailing Address - Country:US
Mailing Address - Phone:252-671-0238
Mailing Address - Fax:
Practice Address - Street 1:3301 W 111TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655-2715
Practice Address - Country:US
Practice Address - Phone:312-469-0486
Practice Address - Fax:773-233-6111
Is Sole Proprietor?:No
Enumeration Date:2017-07-10
Last Update Date:2021-10-05
Deactivation Date:2021-08-26
Deactivation Code:
Reactivation Date:2021-10-05
Provider Licenses
StateLicense IDTaxonomies
IL071010572103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical