Provider Demographics
NPI:1881014926
Name:MADISON CLARK, PLLC
Entity Type:Organization
Organization Name:MADISON CLARK, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MADISON
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MED, LPC
Authorized Official - Phone:214-435-6145
Mailing Address - Street 1:1213 LESLIE LN
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-4403
Mailing Address - Country:US
Mailing Address - Phone:214-435-6145
Mailing Address - Fax:
Practice Address - Street 1:711 W MAIN STREET
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069
Practice Address - Country:US
Practice Address - Phone:405-882-4960
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-16
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5327251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1407195183Medicaid