Provider Demographics
NPI:1891276531
Name:KANKA, MADISON
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:KANKA
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 1:10010 WOODLAND CT
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-1738
Mailing Address - Country:US
Mailing Address - Phone:586-413-4441
Mailing Address - Fax:
Practice Address - Street 1:43996 WOODWARD AVE STE 10
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-5030
Practice Address - Country:US
Practice Address - Phone:586-413-4441
Practice Address - Fax:248-309-3198
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301017570103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist