Healthcare Provider Details

I. General information

NPI: 1164349874
Provider Name (Legal Business Name): MADISON M RAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2026
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 PENINSULA AVE
SAN MATEO CA
94401-1653
US

IV. Provider business mailing address

5444 ALAIRE VIE DR
FAIR OAKS CA
95628-2678
US

V. Phone/Fax

Practice location:
  • Phone: 800-538-8365
  • Fax:
Mailing address:
  • Phone: 916-990-3759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: