Provider Demographics
NPI:1629643937
Name:GORE, MADELINE DIANE (BASW)
Entity Type:Individual
Prefix:MS
First Name:MADELINE
Middle Name:DIANE
Last Name:GORE
Suffix:
Gender:F
Credentials:BASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4729 RUSTIC RD
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-4438
Mailing Address - Country:US
Mailing Address - Phone:916-912-6786
Mailing Address - Fax:
Practice Address - Street 1:4729 RUSTIC RD
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-4438
Practice Address - Country:US
Practice Address - Phone:916-912-6786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-20
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator