Healthcare Provider Details

I. General information

NPI: 1265361455
Provider Name (Legal Business Name): MADISON FIELDS LPC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 PARKER AVE S
BROOKLET GA
30415-8208
US

IV. Provider business mailing address

PO BOX 95
BROOKLET GA
30415-0095
US

V. Phone/Fax

Practice location:
  • Phone: 912-712-1712
  • Fax:
Mailing address:
  • Phone: 912-712-1712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MADISON FIELDS
Title or Position: PRACTICE OWNER
Credential: MED, LPC
Phone: 912-712-1712