Basic Information
| Provider Information | |||||||||
| NPI: | 1073062253 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MADIGAN | ||||||||
| FirstName: | KASSANDRA | ||||||||
| MiddleName: | ENID | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CASAC-T | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BAECKER | ||||||||
| OtherFirstName: | KASSANDRA | ||||||||
| OtherMiddleName: | ENID | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.A. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 55 HORIZON DR | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117434436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6319208000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 55 HORIZON DR | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117434436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6319208000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2016 | ||||||||
| LastUpdateDate: | 12/24/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 34447 | NY | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.