Provider Demographics
NPI:1053877431
Name:BROOKS, MADALYN M
Entity type:Individual
Prefix:
First Name:MADALYN
Middle Name:M
Last Name:BROOKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MADALYN
Other - Middle Name:M
Other - Last Name:HERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1158 WESTWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:VAN WERT
Mailing Address - State:OH
Mailing Address - Zip Code:45891
Mailing Address - Country:US
Mailing Address - Phone:419-238-3434
Mailing Address - Fax:419-238-1955
Practice Address - Street 1:1158 WESTWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:VAN WERT
Practice Address - State:OH
Practice Address - Zip Code:45891
Practice Address - Country:US
Practice Address - Phone:419-238-3434
Practice Address - Fax:419-238-1955
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH34-1475943Medicaid
OH0334859Medicaid