Healthcare Provider Details

I. General information

NPI: 1023555653
Provider Name (Legal Business Name): MADAHI GIZEH MACIAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2017
Last Update Date: 07/21/2023
Certification Date: 07/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7426 CHERRY AVE STE 210-624
FONTANA CA
92336-4221
US

IV. Provider business mailing address

7426 CHERRY AVE STE 210-624
FONTANA CA
92336-4221
US

V. Phone/Fax

Practice location:
  • Phone: 909-265-4566
  • Fax:
Mailing address:
  • Phone: 909-265-4566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number136016
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: