Provider Demographics
NPI:1407676398
Name:FORT, MADDISON (MFTA)
Entity type:Individual
Prefix:
First Name:MADDISON
Middle Name:
Last Name:FORT
Suffix:
Gender:F
Credentials:MFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3104 BLUE LAKE DR STE 101
Mailing Address - Street 2:
Mailing Address - City:VESTAVIA
Mailing Address - State:AL
Mailing Address - Zip Code:35243-2345
Mailing Address - Country:US
Mailing Address - Phone:205-218-3483
Mailing Address - Fax:205-977-3939
Practice Address - Street 1:3104 BLUE LAKE DR STE 101
Practice Address - Street 2:
Practice Address - City:VESTAVIA
Practice Address - State:AL
Practice Address - Zip Code:35243-2345
Practice Address - Country:US
Practice Address - Phone:205-218-3483
Practice Address - Fax:205-977-3939
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-15
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALA286106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist