Healthcare Provider Details

I. General information

NPI: 1083173876
Provider Name (Legal Business Name): GUADALUPE MADRID-LONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 07/29/2025
Certification Date: 07/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 BRISTOL ST
COSTA MESA CA
92626-5996
US

IV. Provider business mailing address

2801 BRISTOL ST
COSTA MESA CA
92626-5996
US

V. Phone/Fax

Practice location:
  • Phone: 949-745-1033
  • Fax:
Mailing address:
  • Phone: 949-745-1033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: