Healthcare Provider Details

I. General information

NPI: 1700649217
Provider Name (Legal Business Name): MADISON HANKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2024
Last Update Date: 02/06/2024
Certification Date: 02/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3D MED BN, 3D MLG, H&S COMPANY, MENTAL HEALTH PLATOON UNIT 38447, OKINAWA JAPAN
FPO AP
96373-8445
US

IV. Provider business mailing address

3256 N 1000 E
OGDEN UT
84414-1713
US

V. Phone/Fax

Practice location:
  • Phone: 801-516-1424
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810008399
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: