Healthcare Provider Details

I. General information

NPI: 1922432319
Provider Name (Legal Business Name): ELLIANA IXTA MADERA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2013
Last Update Date: 08/19/2021
Certification Date: 08/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 E ROSECRANS AVE
COMPTON CA
90221
US

IV. Provider business mailing address

509 E ROSECRANS AVE
COMPTON CA
90221-2056
US

V. Phone/Fax

Practice location:
  • Phone: 213-385-5100
  • Fax:
Mailing address:
  • Phone: 213-385-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number63242
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number63242
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number103120
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: