Provider Demographics
NPI:1972232817
Name:DELORIA, MADELINE (MS, CGC)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:DELORIA
Suffix:
Gender:F
Credentials:MS, CGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 CUMBERLAND RD # 2
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-6242
Mailing Address - Country:US
Mailing Address - Phone:415-305-9454
Mailing Address - Fax:
Practice Address - Street 1:704 CUMBERLAND RD # 2
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-6242
Practice Address - Country:US
Practice Address - Phone:415-305-9454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-07
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MJ00053600170300000X
SD0292170300000X
UT12072723-3601170300000X
AL94170300000X
NE266170300000X
ND0240170300000X
PAGC000721170300000X
WAGT61073601170300000X
IDGEN-255170300000X
ARLCG-0163170300000X
MN1411170300000X
CT363170300000X
OK0414170300000X
LA325656170300000X
CAGC001189170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS