MEDICARE: MADISON LIDDLE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P106340	OTHER	NY	LIMITED PERMIT NUMBER

General Provider Information

NPI Number	:	1073129805
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADISON LIDDLE

Provider Business Mailing Address
First Line	:	371 HUMBOLDT ST APT 208
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11211-2988
Country	:	US
Telephone Number	:	305-582-5618
Fax Number	:

Provider Business Practice Location Address
First Line	:	371 HUMBOLDT ST APT 208
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11211-2988
Country	:	US
Telephone Number	:	305-582-5618
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/17/2020
Last Update Date	:	09/17/2020

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Directions to “ MADISON LIDDLE ” Practice Location

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