Provider Demographics
NPI:1063002905
Name:MADRIGAL, MALENA MARIA
Entity Type:Individual
Prefix:
First Name:MALENA
Middle Name:MARIA
Last Name:MADRIGAL
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 1:1725 W 58TH ST APT 102
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-6853
Mailing Address - Country:US
Mailing Address - Phone:786-667-2558
Mailing Address - Fax:
Practice Address - Street 1:1725 W 58TH ST APT 102
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-6853
Practice Address - Country:US
Practice Address - Phone:786-667-2558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-25
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB618538106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician