Provider Demographics
NPI:1487970026
Name:SPEACH, MADELYNN LORRAINE (CACII)
Entity type:Individual
Prefix:MRS
First Name:MADELYNN
Middle Name:LORRAINE
Last Name:SPEACH
Suffix:
Gender:F
Credentials:CACII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 850
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-0850
Mailing Address - Country:US
Mailing Address - Phone:678-681-4001
Mailing Address - Fax:678-217-5742
Practice Address - Street 1:44 DARBYS CROSSING DR STE 206C
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141
Practice Address - Country:US
Practice Address - Phone:770-222-8535
Practice Address - Fax:770-222-8536
Is Sole Proprietor?:No
Enumeration Date:2010-04-07
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1911-R101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1911-ROtherSUBSTANCE ABUSE TREATMENT