Provider Demographics
NPI:1932678125
Name:MADRID, MARY CHRISTINA
Entity Type:Individual
Prefix:MISS
First Name:MARY
Middle Name:CHRISTINA
Last Name:MADRID
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 1:2445 W WHITES BRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93706-1225
Mailing Address - Country:US
Mailing Address - Phone:559-485-6364
Mailing Address - Fax:
Practice Address - Street 1:2445 W WHITES BRIDGE AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93706-1225
Practice Address - Country:US
Practice Address - Phone:559-485-6364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-16
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100003AN101Y00000X
101YA0400X
CAR1311710618101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA$$$$$$$$$OtherSS#