Basic Information
| Provider Information | |||||||||
| NPI: | 1205171774 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MADISON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MFTI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1604 S. SANTA FE., SUITE 403 | ||||||||
| Address2: | VALLEY-WIDE COUNSELING SERVICES | ||||||||
| City: | SAN JACINTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925834074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516542026 | ||||||||
| FaxNumber: | 9516549927 | ||||||||
| Practice Location | |||||||||
| Address1: | 1604 S. SANTA FE., SUITE 403 | ||||||||
| Address2: | VALLEY-WIDE COUNSELING SERVICES | ||||||||
| City: | SAN JACINTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925834074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516542026 | ||||||||
| FaxNumber: | 9516549927 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2012 | ||||||||
| LastUpdateDate: | 11/18/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | IMF71697 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.