Provider Demographics
NPI:1669948873
Name:MADDEN, MICAELA
Entity type:Individual
Prefix:
First Name:MICAELA
Middle Name:
Last Name:MADDEN
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:PO BOX 33568
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92163-3568
Mailing Address - Country:US
Mailing Address - Phone:855-223-7123
Mailing Address - Fax:619-374-7134
Practice Address - Street 1:2928 JEFFERSON ST STE 100
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-2374
Practice Address - Country:US
Practice Address - Phone:855-223-7123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-16
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 247200000X
CA1-21-53273103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other