Provider Demographics
NPI:1134222920
Name:MADRID, ALEX R (LPC)
Entity type:Individual
Prefix:MR
First Name:ALEX
Middle Name:R
Last Name:MADRID
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1791
Mailing Address - Street 2:
Mailing Address - City:DAVIDSON
Mailing Address - State:NC
Mailing Address - Zip Code:28036-1791
Mailing Address - Country:US
Mailing Address - Phone:704-506-5944
Mailing Address - Fax:
Practice Address - Street 1:19900 S MAIN ST
Practice Address - Street 2:SUITE 4E
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-6512
Practice Address - Country:US
Practice Address - Phone:704-506-5944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2009-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5209101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103419Medicaid