Provider Demographics
NPI:1780905422
Name:MADISON, MARY LEE
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LEE
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 1:1620 PLEASANT ST STE 237
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50314-1676
Mailing Address - Country:US
Mailing Address - Phone:515-244-1716
Mailing Address - Fax:515-221-3519
Practice Address - Street 1:1620 PLEASANT ST STE 237
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-1676
Practice Address - Country:US
Practice Address - Phone:515-244-1716
Practice Address - Fax:515-221-3519
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-17
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1994101YP2500X
TX12889101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional