Provider Demographics
NPI:1336816321
Name:MADDEN, SUMMER (MA, TLLP)
Entity Type:Individual
Prefix:
First Name:SUMMER
Middle Name:
Last Name:MADDEN
Suffix:
Gender:F
Credentials:MA, TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2984 SUNDERLAND
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-2857
Mailing Address - Country:US
Mailing Address - Phone:248-421-2311
Mailing Address - Fax:
Practice Address - Street 1:14533 MACK AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48215-2520
Practice Address - Country:US
Practice Address - Phone:313-231-1771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-26
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362001476103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical