Healthcare Provider Details

I. General information

NPI: 1467388017
Provider Name (Legal Business Name): MADISAN MARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 GREENFIELD RD
BETHLEHEM PA
18017-9312
US

IV. Provider business mailing address

1215 GREENFIELD RD
BETHLEHEM PA
18017-9312
US

V. Phone/Fax

Practice location:
  • Phone: 484-894-6842
  • Fax:
Mailing address:
  • Phone: 484-894-6842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number9509827
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: