Healthcare Provider Details

I. General information

NPI: 1639663867
Provider Name (Legal Business Name): MADALYN MICHELLE MAINHARDT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 01/02/2026
Certification Date: 01/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 CALOR DR
BUELLTON CA
93427-9727
US

IV. Provider business mailing address

314 CALOR DR
BUELLTON CA
93427-9727
US

V. Phone/Fax

Practice location:
  • Phone: 805-705-0744
  • Fax:
Mailing address:
  • Phone: 804-705-0744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number120780
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: