Provider Demographics
NPI:1457558892
Name:MADISON, LANETTE
Entity Type:Individual
Prefix:
First Name:LANETTE
Middle Name:
Last Name:MADISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1244 HARTING DR
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-1971
Mailing Address - Country:US
Mailing Address - Phone:314-680-0218
Mailing Address - Fax:314-839-5978
Practice Address - Street 1:1244 HARTING DR
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-1971
Practice Address - Country:US
Practice Address - Phone:314-680-0218
Practice Address - Fax:314-839-5978
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOSW0059061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical