Provider Demographics
NPI:1992355663
Name:CROSS, MADDISON LYNN
Entity type:Individual
Prefix:
First Name:MADDISON
Middle Name:LYNN
Last Name:CROSS
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 1:1705 GARDENIA AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-2142
Mailing Address - Country:US
Mailing Address - Phone:616-915-8815
Mailing Address - Fax:
Practice Address - Street 1:1705 GARDENIA AVE
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-2142
Practice Address - Country:US
Practice Address - Phone:616-915-8815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801105670104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI947573204-02OtherPRIORITY HEALTH