Healthcare Provider Details

I. General information

NPI: 1164251658
Provider Name (Legal Business Name): BOBBY MADEIRA LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2024
Last Update Date: 07/31/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2314 S VAL VISTA DR STE 100
GILBERT AZ
85295-5570
US

IV. Provider business mailing address

1400 E SOUTHERN AVE STE 735
TEMPE AZ
85282-5699
US

V. Phone/Fax

Practice location:
  • Phone: 480-804-0326
  • Fax: 480-401-3857
Mailing address:
  • Phone: 480-804-0326
  • Fax: 480-804-0083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLAC-22829
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: