Basic Information
| Provider Information | |||||||||
| NPI: | 1508426222 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER-BOTTOME | ||||||||
| FirstName: | MADELEINE | ||||||||
| MiddleName: | |||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 325 DISTEL CIR | ||||||||
| Address2: | |||||||||
| City: | LOS ALTOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940221408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4156005959 | ||||||||
| FaxNumber: | 4153691392 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 DUBOCE AVENUE | ||||||||
| Address2: | |||||||||
| City: | SUITE 250 | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941143389 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4156005959 | ||||||||
| FaxNumber: | 4153691392 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2019 | ||||||||
| LastUpdateDate: | 03/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | 32847 | CA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103TC0700X | 32847 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.