Healthcare Provider Details

I. General information

NPI: 1902739816
Provider Name (Legal Business Name): MCN MADISON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 W HOLUM ST STE A
DEFOREST WI
53532-1108
US

IV. Provider business mailing address

120 W HOLUM ST
DEFOREST WI
53532-1108
US

V. Phone/Fax

Practice location:
  • Phone: 608-912-1672
  • Fax:
Mailing address:
  • Phone: 608-912-1672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY CARLTON
Title or Position: OWNER/PRACTITIONER
Credential: LPC, ICP
Phone: 920-251-4489