Healthcare Provider Details

I. General information

NPI: 1578008710
Provider Name (Legal Business Name): MADELINE RAZAVI LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2016
Last Update Date: 05/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1918 BONITA AVE
BERKELEY CA
94704-1014
US

IV. Provider business mailing address

15632 BAYPOINT AVE
SAN LEANDRO CA
94579-2789
US

V. Phone/Fax

Practice location:
  • Phone: 510-990-2306
  • Fax:
Mailing address:
  • Phone: 510-990-2306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number74846
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: