Provider Demographics
NPI:1316792112
Name:VISLOCKY, MADISON RAE (LPC)
Entity type:Individual
Prefix:MRS
First Name:MADISON
Middle Name:RAE
Last Name:VISLOCKY
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 1:1627 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-1361
Mailing Address - Country:US
Mailing Address - Phone:864-210-3115
Mailing Address - Fax:864-469-5688
Practice Address - Street 1:1627 E NORTH ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-1361
Practice Address - Country:US
Practice Address - Phone:864-210-3115
Practice Address - Fax:864-469-5688
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-23
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8508101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor