Provider Demographics
NPI:1780737718
Name:MADDEN, CHRISTA
Entity type:Individual
Prefix:
First Name:CHRISTA
Middle Name:
Last Name:MADDEN
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:PO BOX 8073
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-0073
Mailing Address - Country:US
Mailing Address - Phone:860-748-5538
Mailing Address - Fax:860-791-8066
Practice Address - Street 1:475 BUCKLAND RD
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-3738
Practice Address - Country:US
Practice Address - Phone:860-748-5538
Practice Address - Fax:860-791-8066
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-21
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004707104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004263125Medicaid