Healthcare Provider Details

I. General information

NPI: 1770337560
Provider Name (Legal Business Name): MADISON TAYLOR MACMASTER BA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2024
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 WILSHIRE BLVD ST 500 #788
LOS ANGELES CA
90017-2603
US

IV. Provider business mailing address

20256 RUSTON RD
WOODLAND HILLS CA
91364-5641
US

V. Phone/Fax

Practice location:
  • Phone: 310-571-5623
  • Fax:
Mailing address:
  • Phone: 310-571-5623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number164521
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: