Provider Demographics
NPI:1356588578
Name:MADERO, ENOC EDUARDO (MA)
Entity type:Individual
Prefix:
First Name:ENOC
Middle Name:EDUARDO
Last Name:MADERO
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6036 BRAMBLEBERRY WAY
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-6618
Mailing Address - Country:US
Mailing Address - Phone:919-593-7602
Mailing Address - Fax:
Practice Address - Street 1:6036 BRAMBLEBERRY WAY
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-6618
Practice Address - Country:US
Practice Address - Phone:919-593-7602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-09
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC252Y00000X, 222Q00000X
251S00000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No252Y00000XAgenciesEarly Intervention Provider Agency
No251S00000XAgenciesCommunity/Behavioral Health
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities