Provider Demographics
NPI:1962080937
Name:MADIEROS, MICHAEL R
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:MADIEROS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6060 MAPLE RD
Mailing Address - Street 2:
Mailing Address - City:FRANKENMUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48734-9715
Mailing Address - Country:US
Mailing Address - Phone:530-815-1747
Mailing Address - Fax:
Practice Address - Street 1:6060 MAPLE RD
Practice Address - Street 2:
Practice Address - City:FRANKENMUTH
Practice Address - State:MI
Practice Address - Zip Code:48734-9715
Practice Address - Country:US
Practice Address - Phone:530-815-1747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIPENDING101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)