Healthcare Provider Details

I. General information

NPI: 1558615252
Provider Name (Legal Business Name): DONALD G DEMADERIOS MA, MFTI, LPCCI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2012
Last Update Date: 02/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4760 SEPULVEDA BLVD
CULVER CITY CA
90230-4820
US

IV. Provider business mailing address

323 N PRAIRIE AVE
INGLEWOOD CA
90301-4502
US

V. Phone/Fax

Practice location:
  • Phone: 310-389-5230
  • Fax: 310-398-5690
Mailing address:
  • Phone: 310-677-7808
  • Fax: 310-846-2139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: