Provider Demographics
NPI:1770126955
Name:OTTJEPKA, MADISON (LMSW)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:OTTJEPKA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:
Other - Last Name:QUEENER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:135 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MARINE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48039-1607
Mailing Address - Country:US
Mailing Address - Phone:810-765-8539
Mailing Address - Fax:
Practice Address - Street 1:6221 KING RD
Practice Address - Street 2:
Practice Address - City:MARINE CITY
Practice Address - State:MI
Practice Address - Zip Code:48039-1428
Practice Address - Country:US
Practice Address - Phone:810-765-8539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
MI68011195211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical