Healthcare Provider Details

I. General information

NPI: 1801724208
Provider Name (Legal Business Name): MADISON MARCAVAGE LPCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 BROADWAY AVENUE EXT
MYSTIC CT
06355-2874
US

IV. Provider business mailing address

1002 RIVER VIEW LN
NORWICH CT
06360-1311
US

V. Phone/Fax

Practice location:
  • Phone: 860-415-3711
  • Fax:
Mailing address:
  • Phone: 860-235-1713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number9242
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: