Healthcare Provider Details

I. General information

NPI: 1447148929
Provider Name (Legal Business Name): CHARLES EDWARD MADISON JR. LLBSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2025
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 E MCNICHOLS RD
DETROIT MI
48203-2857
US

IV. Provider business mailing address

1121 E MCNICHOLS RD
DETROIT MI
48203-2857
US

V. Phone/Fax

Practice location:
  • Phone: 313-365-3100
  • Fax: 313-365-3101
Mailing address:
  • Phone: 313-365-3100
  • Fax: 313-365-3101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6852094022
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: