Provider Demographics
NPI:1518759000
Name:ALCANTARA, MADISON
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:ALCANTARA
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 1:1901 NEWPORT BLVD STE 350
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-2278
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1901 NEWPORT BLVD STE 350
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-2278
Practice Address - Country:US
Practice Address - Phone:909-529-0241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-20
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA155044106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist