Healthcare Provider Details

I. General information

NPI: 1972412997
Provider Name (Legal Business Name): MADISON GRACE MCCORVEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2026
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 E MAIN ST
OLNEY IL
62450-2114
US

IV. Provider business mailing address

516 N ELLIOTT ST
OLNEY IL
62450-3618
US

V. Phone/Fax

Practice location:
  • Phone: 618-395-8656
  • Fax:
Mailing address:
  • Phone: 318-268-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: