Basic Information
| Provider Information | |||||||||
| NPI: | 1629676705 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARPENTER | ||||||||
| FirstName: | MADEA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4653 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WHITEHALL | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432133298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6146530716 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5665 HOOVER RD | ||||||||
| Address2: | |||||||||
| City: | GROVE CITY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431239280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6148752371 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2020 | ||||||||
| LastUpdateDate: | 06/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S.2001575-TRNE | OH | N | Behavioral Health & Social Service Providers | Social Worker | 101Y00000X | S.2001575-TRNE | OH | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.