Provider Demographics
NPI:1639663867
Name:MAINHARDT, MADALYN MICHELLE
Entity Type:Individual
Prefix:
First Name:MADALYN
Middle Name:MICHELLE
Last Name:MAINHARDT
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 1:314 CALOR DR
Mailing Address - Street 2:
Mailing Address - City:BUELLTON
Mailing Address - State:CA
Mailing Address - Zip Code:93427-9727
Mailing Address - Country:US
Mailing Address - Phone:804-705-0744
Mailing Address - Fax:
Practice Address - Street 1:1722 S LEWIS RD
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-8520
Practice Address - Country:US
Practice Address - Phone:805-366-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health