Healthcare Provider Details

I. General information

NPI: 1487236956
Provider Name (Legal Business Name): MADELEINE RABEN HEGARTY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2021
Last Update Date: 04/24/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14220 SW 86TH AVE
PALMETTO BAY FL
33158-1452
US

IV. Provider business mailing address

14220 SW 86TH AVE
PALMETTO BAY FL
33158-1452
US

V. Phone/Fax

Practice location:
  • Phone: 786-390-2559
  • Fax:
Mailing address:
  • Phone: 786-390-2559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberSW15610
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: