Provider Demographics
NPI:1962160234
Name:MADRIAGA, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MADRIAGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 303
Mailing Address - Street 2:
Mailing Address - City:KEWASKUM
Mailing Address - State:WI
Mailing Address - Zip Code:53040-0303
Mailing Address - Country:US
Mailing Address - Phone:920-960-5890
Mailing Address - Fax:
Practice Address - Street 1:314 1ST ST
Practice Address - Street 2:
Practice Address - City:KEWASKUM
Practice Address - State:WI
Practice Address - Zip Code:53040-8930
Practice Address - Country:US
Practice Address - Phone:920-960-5890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-03
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health