Provider Demographics
NPI:1467034595
Name:MADRID, DAVID (BA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:MADRID
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 N ALDER AVE
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20164-4013
Mailing Address - Country:US
Mailing Address - Phone:267-671-7977
Mailing Address - Fax:
Practice Address - Street 1:305 N ALDER AVE
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20164-4013
Practice Address - Country:US
Practice Address - Phone:267-671-7977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-27
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-21-165724106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician