Healthcare Provider Details

I. General information

NPI: 1760638043
Provider Name (Legal Business Name): ANGELLO MADISON LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MR. ANGELLO MADISON

II. Dates (important events)

Enumeration Date: 08/18/2008
Last Update Date: 07/09/2021
Certification Date: 07/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 N MAIN ST STE 102A
SUFFOLK VA
23434-4564
US

IV. Provider business mailing address

114 N MAIN ST STE 102A
SUFFOLK VA
23434-4564
US

V. Phone/Fax

Practice location:
  • Phone: 757-921-2762
  • Fax:
Mailing address:
  • Phone: 757-921-2762
  • Fax: 757-257-1011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number07010007132
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: