Provider Demographics
NPI:1568892297
Name:MADRIGAL, RICHARD THOMAS
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:THOMAS
Last Name:MADRIGAL
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 1:12072 SAINT MARK ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92845-1615
Mailing Address - Country:US
Mailing Address - Phone:310-849-9495
Mailing Address - Fax:
Practice Address - Street 1:1231 E DYER RD STE 135
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-5643
Practice Address - Country:US
Practice Address - Phone:714-944-7132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-15
Last Update Date:2023-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX205089106H00000X
CA124038106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist