Provider Demographics
NPI:1912601238
Name:MADURO, ROSALIE S
Entity Type:Individual
Prefix:
First Name:ROSALIE
Middle Name:S
Last Name:MADURO
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 1:1501 LINCOLN BLVD
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-3503
Mailing Address - Country:US
Mailing Address - Phone:215-584-2973
Mailing Address - Fax:
Practice Address - Street 1:1748 WASHINGTON WAY
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-4702
Practice Address - Country:US
Practice Address - Phone:202-841-4645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-29
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA136948106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist