Provider Demographics
NPI:1831841980
Name:ST JOHN, MADISON
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:ST JOHN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 S PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-3578
Mailing Address - Country:US
Mailing Address - Phone:443-805-9853
Mailing Address - Fax:
Practice Address - Street 1:7310 GOVERNOR RITCHIE HWY STE 1009
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-3398
Practice Address - Country:US
Practice Address - Phone:410-768-5988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-20
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC14657101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health