Provider Demographics
NPI:1821739137
Name:DE PERALTA, MADISON K
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:K
Last Name:DE PERALTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MADDIE
Other - Middle Name:K
Other - Last Name:DE PERALTA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:18400 PRAIRIE ST APT 231
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-2236
Mailing Address - Country:US
Mailing Address - Phone:818-451-7214
Mailing Address - Fax:
Practice Address - Street 1:9335 RESEDA BLVD STE 101
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324-2977
Practice Address - Country:US
Practice Address - Phone:818-960-0630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-02
Last Update Date:2022-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician