Provider Demographics
NPI:1740057033
Name:THOMAS, MADISON (LCSW)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 S 2000 W BLDG STE 105
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:UT
Mailing Address - Zip Code:84075-9602
Mailing Address - Country:US
Mailing Address - Phone:801-332-9201
Mailing Address - Fax:
Practice Address - Street 1:780 S 2000 W BLDG STE 105
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:UT
Practice Address - Zip Code:84075-9602
Practice Address - Country:US
Practice Address - Phone:801-332-9201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-06
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1196286135011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical