Healthcare Provider Details

I. General information

NPI: 1487306593
Provider Name (Legal Business Name): MADISON R MARSHALL LCMHCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2022
Last Update Date: 03/13/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1806 S 15TH ST
WILMINGTON NC
28401-6479
US

IV. Provider business mailing address

615 SHIPYARD BLVD
WILMINGTON NC
28412-6431
US

V. Phone/Fax

Practice location:
  • Phone: 910-772-2515
  • Fax:
Mailing address:
  • Phone: 910-343-0145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA19385
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberA19385
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: