Provider Demographics
NPI:1992376131
Name:MADRIAGA, ELOISE (CADC1, MPSS)
Entity Type:Individual
Prefix:
First Name:ELOISE
Middle Name:
Last Name:MADRIAGA
Suffix:
Gender:F
Credentials:CADC1, MPSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 N DATE ST
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-3405
Mailing Address - Country:US
Mailing Address - Phone:760-745-7786
Mailing Address - Fax:
Practice Address - Street 1:161 N DATE ST
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-3405
Practice Address - Country:US
Practice Address - Phone:760-745-7786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-08
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CAMPSS-QTDFEW175T00000X
CACI38700623101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No175T00000XOther Service ProvidersPeer Specialist