Provider Demographics
NPI:1760638043
Name:MADISON, ANGELLO (LPC)
Entity Type:Individual
Prefix:MR
First Name:ANGELLO
Middle Name:
Last Name:MADISON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:MR
Other - First Name:ANGELLO
Other - Middle Name:
Other - Last Name:MADISON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:114 N MAIN ST STE 102A
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-4564
Mailing Address - Country:US
Mailing Address - Phone:757-921-2762
Mailing Address - Fax:757-257-1011
Practice Address - Street 1:114 N MAIN ST STE 102A
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-4564
Practice Address - Country:US
Practice Address - Phone:757-921-2762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-18
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA07010007132251S00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health