Provider Demographics
NPI:1295933380
Name:WHITE-MADSEN, KRISTEN DENISE (LCSW)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:DENISE
Last Name:WHITE-MADSEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1708 BANYAN CT
Mailing Address - Street 2:
Mailing Address - City:CERES
Mailing Address - State:CA
Mailing Address - Zip Code:95307-1907
Mailing Address - Country:US
Mailing Address - Phone:095-312-0882
Mailing Address - Fax:
Practice Address - Street 1:3607 BLAKER RD
Practice Address - Street 2:
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307-9503
Practice Address - Country:US
Practice Address - Phone:209-531-2088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2023-07-31
Deactivation Date:2018-03-02
Deactivation Code:
Reactivation Date:2018-03-08
Provider Licenses
StateLicense IDTaxonomies
CAASW31516101YM0800X
CALCSW817341041C0700X
CA817341041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health