Healthcare Provider Details

I. General information

NPI: 1508426222
Provider Name (Legal Business Name): MADELEINE MILLER-BOTTOME PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2019
Last Update Date: 03/02/2022
Certification Date: 02/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 DUBOCE AVENUE
SUITE 250 CA
94114-3389
US

IV. Provider business mailing address

325 DISTEL CIR
LOS ALTOS CA
94022-1408
US

V. Phone/Fax

Practice location:
  • Phone: 415-600-5959
  • Fax: 415-369-1392
Mailing address:
  • Phone: 415-600-5959
  • Fax: 415-369-1392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number32847
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number32847
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: