Provider Demographics
NPI:1003160912
Name:MADISON, GILBERT DIALLO (SUDCC III-CS)
Entity Type:Individual
Prefix:
First Name:GILBERT
Middle Name:DIALLO
Last Name:MADISON
Suffix:
Gender:M
Credentials:SUDCC III-CS
Other - Prefix:
Other - First Name:G.
Other - Middle Name:DIALLO
Other - Last Name:MADISON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:SUDCC III - CS
Mailing Address - Street 1:705 W LA VETA AVE STE 208
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4448
Mailing Address - Country:US
Mailing Address - Phone:714-532-9295
Mailing Address - Fax:
Practice Address - Street 1:705 W LA VETA AVE STE 208
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4448
Practice Address - Country:US
Practice Address - Phone:714-532-9295
Practice Address - Fax:714-532-9291
Is Sole Proprietor?:No
Enumeration Date:2012-10-30
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6230101YA0400X, 101YA0400X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)