Provider Demographics
NPI:1437992302
Name:CLARK, MADISON LINN (LSW)
Entity type:Individual
Prefix:MRS
First Name:MADISON
Middle Name:LINN
Last Name:CLARK
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:MISS
Other - First Name:MADISON
Other - Middle Name:LINN
Other - Last Name:FLAHERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:46 HEATHER CT
Mailing Address - Street 2:
Mailing Address - City:GENESEO
Mailing Address - State:IL
Mailing Address - Zip Code:61254-9150
Mailing Address - Country:US
Mailing Address - Phone:309-945-3682
Mailing Address - Fax:
Practice Address - Street 1:415 N PERRY ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52801-1617
Practice Address - Country:US
Practice Address - Phone:309-945-3682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.104621104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker