Provider Demographics
NPI:1023555653
Name:MACIAS, MADAHI GIZEH
Entity Type:Individual
Prefix:
First Name:MADAHI
Middle Name:GIZEH
Last Name:MACIAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7426 CHERRY AVE STE 210-624
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-4221
Mailing Address - Country:US
Mailing Address - Phone:909-265-4566
Mailing Address - Fax:
Practice Address - Street 1:7426 CHERRY AVE STE 210-624
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-4221
Practice Address - Country:US
Practice Address - Phone:909-265-4566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-20
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA136016106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician