Healthcare Provider Details

I. General information

NPI: 1487198578
Provider Name (Legal Business Name): PATRICK J. MADDEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2016
Last Update Date: 12/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 MARIN ST SUITE 108
THOUSAND OAKS CA
91360-4260
US

IV. Provider business mailing address

501 MARIN ST SUITE 108
THOUSAND OAKS CA
91360-4260
US

V. Phone/Fax

Practice location:
  • Phone: 805-529-2255
  • Fax:
Mailing address:
  • Phone: 805-529-2255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1460
License Number StateCA

VIII. Authorized Official

Name: MR. PATRICK J. MADDEN
Title or Position: LICENSED EDUCATIONAL PSYCHOLOGIST
Credential: MA, LEP
Phone: 805-529-2255