Provider Demographics
NPI:1518459320
Name:WEBB, MADISON
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:WEBB
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 1:600 N ARROWHEAD AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92401-1148
Mailing Address - Country:US
Mailing Address - Phone:909-522-4656
Mailing Address - Fax:909-763-5525
Practice Address - Street 1:1053 N D ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410
Practice Address - Country:US
Practice Address - Phone:909-522-4656
Practice Address - Fax:909-763-5525
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-06
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA113998106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty