Basic Information
| Provider Information | |||||||||
| NPI: | 1194946582 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MADSEN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CADC II | ||||||||
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| Mailing Information | |||||||||
| Address1: | 440 HENDERSON ST | ||||||||
| Address2: | SIUTE C | ||||||||
| City: | GRASS VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959457374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302739541 | ||||||||
| FaxNumber: | 5302737740 | ||||||||
| Practice Location | |||||||||
| Address1: | 440 HENDERSON ST | ||||||||
| Address2: | SIUTE C | ||||||||
| City: | GRASS VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959457374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302739541 | ||||||||
| FaxNumber: | 5302737740 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| LastUpdateDate: | 05/05/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 101YA0400X | A8539205 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.