Healthcare Provider Details

I. General information

NPI: 1174357172
Provider Name (Legal Business Name): MADISON BRUCE BSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2024
Last Update Date: 08/30/2024
Certification Date: 08/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 N BOONE ST
OLNEY IL
62450-2109
US

IV. Provider business mailing address

106 EDWARDS ST
NEWTON IL
62448-1736
US

V. Phone/Fax

Practice location:
  • Phone: 618-392-3226
  • Fax:
Mailing address:
  • Phone: 618-783-4154
  • Fax: 618-783-2339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: