Provider Demographics
NPI:1801941224
Name:DAVIS, MADRIGO (LPC)
Entity type:Individual
Prefix:MS
First Name:MADRIGO
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 CARDINAL WOODS WAY
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29642-1537
Mailing Address - Country:US
Mailing Address - Phone:678-480-5826
Mailing Address - Fax:
Practice Address - Street 1:3300 BUCKEYE RD
Practice Address - Street 2:SUITE 811
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341-4229
Practice Address - Country:US
Practice Address - Phone:770-220-0477
Practice Address - Fax:770-220-0478
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004150101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10066064OtherAMERIGROUP
GA52210317 001OtherBCBSGA BEHAVIORAL HEALTH
GA103665OtherPEACHSTATE HEALTH PLAN
GA467617883BMedicaid
GA10066064OtherCENPATICO BEHAVIORAL HEAL