Provider Demographics
NPI:1104599356
Name:MADISON, SUSIE MARIE (LPC)
Entity type:Individual
Prefix:
First Name:SUSIE
Middle Name:MARIE
Last Name:MADISON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15755 SW OAKHILL LN
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-5643
Mailing Address - Country:US
Mailing Address - Phone:972-730-6444
Mailing Address - Fax:
Practice Address - Street 1:1136 N COTTONWOOD DR
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-3762
Practice Address - Country:US
Practice Address - Phone:972-730-6444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-25
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX77785101YP2500X
ORC7098101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional