Healthcare Provider Details

I. General information

NPI: 1366895450
Provider Name (Legal Business Name): CANDIDA R MADRIGAL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2016
Last Update Date: 01/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

283 BUTLER RD
MOUNT GRETNA PA
17064-6085
US

IV. Provider business mailing address

283 BUTLER RD
MOUNT GRETNA PA
17064-6085
US

V. Phone/Fax

Practice location:
  • Phone: 717-273-8871
  • Fax: 717-273-2732
Mailing address:
  • Phone: 717-273-8871
  • Fax: 717-279-2792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW019064
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS22862
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: