Provider Demographics
NPI:1568831386
Name:MADISON, MARJAN SMITH (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARJAN
Middle Name:SMITH
Last Name:MADISON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9107 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-5531
Mailing Address - Country:US
Mailing Address - Phone:310-275-2212
Mailing Address - Fax:310-275-2212
Practice Address - Street 1:9107 WILSHIRE BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-5531
Practice Address - Country:US
Practice Address - Phone:310-275-2212
Practice Address - Fax:310-275-2212
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-22
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18126103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist