Provider Demographics
| NPI: | 1497269609 |
|---|---|
| Name: | MADISON, DAVID MARK (MALLP) |
| Entity type: | Individual |
| Prefix: | |
| First Name: | DAVID |
| Middle Name: | MARK |
| Last Name: | MADISON |
| Suffix: | |
| Gender: | M |
| Credentials: | MALLP |
| Other - Prefix: | |
| Other - First Name: | |
| Other - Middle Name: | |
| Other - Last Name: | |
| Other - Suffix: | |
| Other - Last Name Type: | |
| Other - Credentials: | |
| Mailing Address - Street 1: | 19445 W WARREN AVE |
| Mailing Address - Street 2: | |
| Mailing Address - City: | DETROIT |
| Mailing Address - State: | MI |
| Mailing Address - Zip Code: | 48228-3361 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 313-307-0088 |
| Mailing Address - Fax: | 313-281-2235 |
| Practice Address - Street 1: | 19445 W WARREN AVE |
| Practice Address - Street 2: | |
| Practice Address - City: | DETROIT |
| Practice Address - State: | MI |
| Practice Address - Zip Code: | 48228-3361 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 313-307-0088 |
| Practice Address - Fax: | 313-281-2235 |
| Is Sole Proprietor?: | Yes |
| Enumeration Date: | 2017-11-27 |
| Last Update Date: | 2022-05-21 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| MI | 6361006967 | 103T00000X |
| 6301009487 | 103K00000X | |
| MI | 6301009487 | 103T00000X, 103TA0400X, 103TA0700X, 103TB0200X, 103TC1900X, 103TC2200X, 103TE1100X, 103TF0000X, 103TF0200X, 103TP0814X, 103TP2701X, 103TR0400X, 103TC0700X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization |
|---|---|---|---|---|
| Yes | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical |
| Yes | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | |
| No | 103K00000X | Behavioral Health & Social Service Providers | Behavior Analyst | |
| No | 103TA0400X | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) |
| No | 103TA0700X | Behavioral Health & Social Service Providers | Psychologist | Adult Development & Aging |
| No | 103TB0200X | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral |
| No | 103TC1900X | Behavioral Health & Social Service Providers | Psychologist | Counseling |
| No | 103TC2200X | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
| No | 103TE1100X | Behavioral Health & Social Service Providers | Psychologist | Exercise & Sports |
| No | 103TF0000X | Behavioral Health & Social Service Providers | Psychologist | Family |
| No | 103TF0200X | Behavioral Health & Social Service Providers | Psychologist | Forensic |
| No | 103TP0814X | Behavioral Health & Social Service Providers | Psychologist | Psychoanalysis |
| No | 103TP2701X | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy |
| No | 103TR0400X | Behavioral Health & Social Service Providers | Psychologist | Rehabilitation |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| MI | XYU992710983 | Other | BLUE CROSS COMPLETE |
| MI | XYU992710983 | Medicaid |
