Provider Demographics
NPI:1235443755
Name:MADSON, CHARLES MICHAEL
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:MICHAEL
Last Name:MADSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 E OCEAN AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-7000
Mailing Address - Country:US
Mailing Address - Phone:805-735-7525
Mailing Address - Fax:805-737-0524
Practice Address - Street 1:1017 E OCEAN AVE
Practice Address - Street 2:SUITE B
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-7000
Practice Address - Country:US
Practice Address - Phone:805-735-7525
Practice Address - Fax:805-737-0524
Is Sole Proprietor?:No
Enumeration Date:2010-07-27
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA420030BN101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)