Healthcare Provider Details

I. General information

NPI: 1902577182
Provider Name (Legal Business Name): MADELYN MCLEAN LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2021
Last Update Date: 09/27/2021
Certification Date: 09/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8687 E VIA DE VENTURA STE 218
SCOTTSDALE AZ
85258-3348
US

IV. Provider business mailing address

3024 E SIESTA LN
PHOENIX AZ
85050-2509
US

V. Phone/Fax

Practice location:
  • Phone: 214-762-0155
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: