Provider Demographics
NPI:1659969038
Name:AID, MADISEN ELYSSA
Entity Type:Individual
Prefix:
First Name:MADISEN
Middle Name:ELYSSA
Last Name:AID
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 1:3410 TAUSSIG ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-3216
Mailing Address - Country:US
Mailing Address - Phone:619-830-7030
Mailing Address - Fax:
Practice Address - Street 1:11650 IBERIA PL STE 130
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2431
Practice Address - Country:US
Practice Address - Phone:800-434-8923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-01
Last Update Date:2021-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA009846663-03OtherTRICARE