Healthcare Provider Details

I. General information

NPI: 1417918285
Provider Name (Legal Business Name): MADELON JEAN PARKS PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 05/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 CONCORD RD
FLETCHER NC
28732-9734
US

IV. Provider business mailing address

455 CONCORD RD
FLETCHER NC
28732-9734
US

V. Phone/Fax

Practice location:
  • Phone: 828-329-8306
  • Fax: 828-258-3831
Mailing address:
  • Phone: 828-329-8306
  • Fax: 828-258-3831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2915
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2915
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: