MEDICARE: MS. MARY LOUISE MADISON MFTI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	IMF71697	CA

General Provider Information

NPI Number	:	1205171774
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY LOUISE MADISON MFTI

Provider Business Mailing Address
First Line	:	1604 S. SANTA FE., SUITE 403
Second Line	:	VALLEY-WIDE COUNSELING SERVICES
City	:	SAN JACINTO
State	:	CA
Zip	:	92583-4074
Country	:	US
Telephone Number	:	951-654-2026
Fax Number	:	951-654-9927

Provider Business Practice Location Address
First Line	:	1604 S. SANTA FE., SUITE 403
Second Line	:	VALLEY-WIDE COUNSELING SERVICES
City	:	SAN JACINTO
State	:	CA
Zip	:	92583-4074
Country	:	US
Telephone Number	:	951-654-2026
Fax Number	:	951-654-9927

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/10/2012
Last Update Date	:	11/18/2013

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