Healthcare Provider Details

I. General information

NPI: 1902729700
Provider Name (Legal Business Name): MADISON MALLOY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 COLONY PARK DR STE 300
CUMMING GA
30040-2773
US

IV. Provider business mailing address

1160 JOHNSON FY RD NE UNIT 1357
SANDY SPRINGS GA
30342-2299
US

V. Phone/Fax

Practice location:
  • Phone: 770-335-1988
  • 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 StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: