Provider Demographics
NPI:1427399377
Name:MADARA, RAEQUEL ALLYSSA (PMHNP, LCSW)
Entity type:Individual
Prefix:MRS
First Name:RAEQUEL
Middle Name:ALLYSSA
Last Name:MADARA
Suffix:
Gender:F
Credentials:PMHNP, LCSW
Other - Prefix:
Other - First Name:RAEQUEL
Other - Middle Name:ALLYSSA
Other - Last Name:FORBES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:145 E GREENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LANSDOWNE
Mailing Address - State:PA
Mailing Address - Zip Code:19050-1621
Mailing Address - Country:US
Mailing Address - Phone:610-368-7737
Mailing Address - Fax:
Practice Address - Street 1:527 E LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:SHILLINGTON
Practice Address - State:PA
Practice Address - Zip Code:19607-1364
Practice Address - Country:US
Practice Address - Phone:610-796-8110
Practice Address - Fax:610-796-9130
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-01
Last Update Date:2025-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0175381041C0700X
PASP032464363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA104516608-0001Medicaid