Provider Demographics
NPI:1649003021
Name:GRAGG, MADISON L (LSW)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:L
Last Name:GRAGG
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 WASHINGTON DR
Mailing Address - Street 2:
Mailing Address - City:BRIGANTINE
Mailing Address - State:NJ
Mailing Address - Zip Code:08203-3020
Mailing Address - Country:US
Mailing Address - Phone:609-705-5338
Mailing Address - Fax:
Practice Address - Street 1:325 EAST JIMMIE LEEDS RD.
Practice Address - Street 2:STE. 7 #270
Practice Address - City:GALLOWAY
Practice Address - State:NJ
Practice Address - Zip Code:08205
Practice Address - Country:US
Practice Address - Phone:609-703-8270
Practice Address - Fax:609-646-3235
Is Sole Proprietor?:No
Enumeration Date:2024-08-21
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06972100104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker