Healthcare Provider Details

I. General information

NPI: 1942004007
Provider Name (Legal Business Name): MADISON MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2025
Last Update Date: 04/01/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 PROVIDENCE RD STE 20
VIRGINIA BEACH VA
23464-4128
US

IV. Provider business mailing address

3511 IDLEWOOD AVE
RICHMOND VA
23221-3413
US

V. Phone/Fax

Practice location:
  • Phone: 757-347-8840
  • Fax:
Mailing address:
  • Phone: 757-285-1291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904016513
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: