Provider Demographics
NPI:1760549885
Name:LICHT, MADONNA MARIA (LCSW LMHP)
Entity Type:Individual
Prefix:MRS
First Name:MADONNA
Middle Name:MARIA
Last Name:LICHT
Suffix:
Gender:F
Credentials:LCSW LMHP
Other - Prefix:MISS
Other - First Name:MADONNA
Other - Middle Name:MARIA
Other - Last Name:GIAGO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW LMHP
Mailing Address - Street 1:3300 NO 60TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68104
Mailing Address - Country:US
Mailing Address - Phone:402-554-0520
Mailing Address - Fax:402-551-8797
Practice Address - Street 1:1490 NO 16TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68102
Practice Address - Country:US
Practice Address - Phone:402-827-0570
Practice Address - Fax:402-827-0580
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE8051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47037661286Medicaid