Provider Demographics
NPI:1700565132
Name:HERZOG, MADELYN (LCSW)
Entity type:Individual
Prefix:
First Name:MADELYN
Middle Name:
Last Name:HERZOG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-2424
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-2424
Practice Address - Country:US
Practice Address - Phone:207-795-4160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-13
Last Update Date:2025-05-14
Deactivation Date:2024-02-09
Deactivation Code:
Reactivation Date:2024-06-04
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
MELC223751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical