Provider Demographics
NPI:1023797693
Name:MADOW, LANCE
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:
Last Name:MADOW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 E TRINITY PL UNIT 1423
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-3493
Mailing Address - Country:US
Mailing Address - Phone:727-916-2257
Mailing Address - Fax:
Practice Address - Street 1:3495 PIEDMONT RD NE
Practice Address - Street 2:BUILDING 10, SUITE 100
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305
Practice Address - Country:US
Practice Address - Phone:770-758-7817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health