Healthcare Provider Details

I. General information

NPI: 1780248609
Provider Name (Legal Business Name): GAVIN K MADEIRA LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2019
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 W VISTA WAY
VISTA CA
92083-5732
US

IV. Provider business mailing address

4856 SUMAC PL
OCEANSIDE CA
92057-5423
US

V. Phone/Fax

Practice location:
  • Phone: 760-758-1092
  • Fax:
Mailing address:
  • Phone: 760-390-2508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number97560
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number123910
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: