Healthcare Provider Details

I. General information

NPI: 1578062022
Provider Name (Legal Business Name): MADELEINE ROSE CAMPBELL TRUJILLO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2018
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4470 21ST ST # 3156
LONG ISLAND CITY NY
11101-5114
US

IV. Provider business mailing address

4470 21ST ST # 3156
LONG ISLAND CITY NY
11101-5114
US

V. Phone/Fax

Practice location:
  • Phone: 516-847-4438
  • Fax:
Mailing address:
  • Phone: 347-224-5214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number089363
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number104808
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: