Provider Demographics
NPI:1598414807
Name:DIRKES, MADISON
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:DIRKES
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 1:45356 VIA JACA
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592
Mailing Address - Country:US
Mailing Address - Phone:720-505-9682
Mailing Address - Fax:
Practice Address - Street 1:40925 COUNTY CENTER DR STE 110
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-6037
Practice Address - Country:US
Practice Address - Phone:951-940-6233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-22
Last Update Date:2023-04-17
Deactivation Date:2022-03-30
Deactivation Code:
Reactivation Date:2022-06-08
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
CAMPSS-BHKNWJ175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health