Provider Demographics
NPI:1972228823
Name:MADISON, KEYSHA
Entity Type:Individual
Prefix:
First Name:KEYSHA
Middle Name:
Last Name:MADISON
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 1:101 S JENNINGS AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-1118
Mailing Address - Country:US
Mailing Address - Phone:214-531-4831
Mailing Address - Fax:
Practice Address - Street 1:101 S JENNINGS AVE STE 203
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-1118
Practice Address - Country:US
Practice Address - Phone:214-531-4831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical