Healthcare Provider Details

I. General information

NPI: 1396572822
Provider Name (Legal Business Name): ILY MADISON MACPHERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2024
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 13
LAKE ELSINORE CA
92531-0013
US

IV. Provider business mailing address

31724 CASINO DR
LAKE ELSINORE CA
92531-1701
US

V. Phone/Fax

Practice location:
  • Phone: 949-573-2489
  • Fax:
Mailing address:
  • Phone: 949-573-2489
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: