=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871613471
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTINE MADRUGA PSY.D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2007
-----------------------------------------------------
Last Update Date | 07/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 613 1ST ST STE 213
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94513-1362
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-608-8736
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1855 ST MICHAELS WAY
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94513-1758
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-550-9690
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY21308
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------