MEDICARE: MADALYN MARIE DERRICK LCSW

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	1041C0700X	Clinical Social Worker	P017676	NC
2	1041C0700X	Clinical Social Worker	C018606	NC

General Provider Information

NPI Number	:	1174254619
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADALYN MARIE DERRICK LCSW

Provider Business Mailing Address
First Line	:	8206 VILLAGE HARBOR DR
Second Line	:
City	:	CORNELIUS
State	:	NC
Zip	:	28031-3706
Country	:	US
Telephone Number	:	407-803-2390
Fax Number	:

Provider Business Practice Location Address
First Line	:	8206 VILLAGE HARBOR DR
Second Line	:
City	:	CORNELIUS
State	:	NC
Zip	:	28031-3706
Country	:	US
Telephone Number	:	407-803-2390
Fax Number	:

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

Provider Enumeration Date	:	06/23/2022
Last Update Date	:	07/22/2025

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