Provider Demographics
NPI:1255139960
Name:MADISON, CONNIE
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:MADISON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18640 MACK AVE # 842
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-7700
Mailing Address - Country:US
Mailing Address - Phone:313-825-4838
Mailing Address - Fax:
Practice Address - Street 1:12411 E 7 MILE RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48205-2154
Practice Address - Country:US
Practice Address - Phone:313-526-3460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-06
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker