Provider Demographics
NPI:1730521972
Name:BURBANK, MADELYN M (LCSW)
Entity type:Individual
Prefix:
First Name:MADELYN
Middle Name:M
Last Name:BURBANK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MADELYN
Other - Middle Name:
Other - Last Name:AMENTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1786 MOON LAKE BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:HOFFMAN ESTATES
Mailing Address - State:IL
Mailing Address - Zip Code:60169-5029
Mailing Address - Country:US
Mailing Address - Phone:847-755-8090
Mailing Address - Fax:847-843-7393
Practice Address - Street 1:1786 MOON LAKE BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60169-5029
Practice Address - Country:US
Practice Address - Phone:847-755-8090
Practice Address - Fax:847-843-7393
Is Sole Proprietor?:No
Enumeration Date:2013-07-29
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.013807104100000X
IL149.0174851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker