Basic Information
Provider Information | |||||||||
NPI: | 1174614903 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MADDEN | ||||||||
FirstName: | HARRIET | ||||||||
MiddleName: | BAER | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMFT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MADDEN | ||||||||
OtherFirstName: | HARRIET | ||||||||
OtherMiddleName: | BAER | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 250 DEWEY AVE | ||||||||
Address2: |   | ||||||||
City: | SPARTANBURG | ||||||||
State: | SC | ||||||||
PostalCode: | 293033009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8645850366 | ||||||||
FaxNumber: | 8645859208 | ||||||||
Practice Location | |||||||||
Address1: | 250 DEWEY AVE | ||||||||
Address2: |   | ||||||||
City: | SPARTANBURG | ||||||||
State: | SC | ||||||||
PostalCode: | 293033009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8645850366 | ||||||||
FaxNumber: | 8645859208 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/27/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 2493 | SC | Y |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 121328 | 05 | SC |   | MEDICAID |