Healthcare Provider Details

I. General information

NPI: 1568263283
Provider Name (Legal Business Name): MADISON WYATT LCSWA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2025
Last Update Date: 08/28/2025
Certification Date: 08/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

231 N SPRING ST
GREENSBORO NC
27401-2231
US

IV. Provider business mailing address

508 W CAMERON AVE
CHAPEL HILL NC
27516-2711
US

V. Phone/Fax

Practice location:
  • Phone: 336-848-3780
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP022514
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: