Basic Information
| Provider Information | |||||||||
| NPI: | 1407988520 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MADISON | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 LAKEWOOD DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | MORRIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604503352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159426323 | ||||||||
| FaxNumber: | 8159426423 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 N HAMMES AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | JOLIET | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604356680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159426323 | ||||||||
| FaxNumber: | 8159426423 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 12/21/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 149-002698 | IL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 149-002698 | 01 | IL | LCSW | OTHER |