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General NPI Number Information
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NPI Number | 1760638043
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Entity Type | Individual
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Provider Name | ANGELLO MADISON LPC
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Gender | Male
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Dates
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Enumeration Date | 08/18/2008
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Last Update Date | 07/09/2021
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Provider Practice Location Address
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Address Line | 114 N MAIN ST STE 102A
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City | SUFFOLK
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State | VA
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Zip | 23434-4564
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Country | US
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Telephone | 757-921-2762
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Fax |
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Provider Business Mailing Address
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Address Line | 114 N MAIN ST STE 102A
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City | SUFFOLK
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State | VA
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Zip | 23434-4564
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Country | US
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Telephone | 757-921-2762
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Fax | 757-257-1011
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 07010007132
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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