Provider Demographics
NPI:1881459402
Name:HEAD, MADILYN ELIZABETH (MS, LCGC)
Entity type:Individual
Prefix:
First Name:MADILYN
Middle Name:ELIZABETH
Last Name:HEAD
Suffix:
Gender:F
Credentials:MS, LCGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 VENTURA DR
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98465-1111
Mailing Address - Country:US
Mailing Address - Phone:989-619-1564
Mailing Address - Fax:
Practice Address - Street 1:912 VENTURA DR
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98465-1111
Practice Address - Country:US
Practice Address - Phone:989-619-1564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-14
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAGT61495152170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS