Provider Demographics
NPI:1265001861
Name:MADISON, KUUMBA (LPT, RADT II)
Entity Type:Individual
Prefix:MR
First Name:KUUMBA
Middle Name:
Last Name:MADISON
Suffix:
Gender:M
Credentials:LPT, RADT II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5047 IVYLEAF SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94582-6018
Mailing Address - Country:US
Mailing Address - Phone:707-208-2051
Mailing Address - Fax:
Practice Address - Street 1:1776 YGNACIO VALLEY RD STE 206
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-3125
Practice Address - Country:US
Practice Address - Phone:707-208-2051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-18
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32557167G00000X
CA14121101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No167G00000XNursing Service ProvidersLicensed Psychiatric Technician