Provider Demographics
NPI:1396244083
Name:MYRICK, MADISON S (LCSW)
Entity type:Individual
Prefix:MRS
First Name:MADISON
Middle Name:S
Last Name:MYRICK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1714 LAWRENCE RD
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-4823
Mailing Address - Country:US
Mailing Address - Phone:404-680-7373
Mailing Address - Fax:
Practice Address - Street 1:1714 LAWRENCE RD
Practice Address - Street 2:
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-4823
Practice Address - Country:US
Practice Address - Phone:404-680-7373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-07
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI40321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty