MEDICARE: DR. MADELINE ECCLESTON PSYD

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	103T00000X	Psychologist	PSY34567	CA
2	103TC0700X	Clinical Psychologist	PSY34567	CA

General Provider Information

NPI Number	:	1578440954
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MADELINE ECCLESTON PSYD

Provider Business Mailing Address
First Line	:	1001 FREMONT AVE UNIT 1073
Second Line	:
City	:	SOUTH PASADENA
State	:	CA
Zip	:	91031-7048
Country	:	US
Telephone Number	:	626-214-8771
Fax Number	:

Provider Business Practice Location Address
First Line	:	1001 FREMONT AVE UNIT 1073
Second Line	:
City	:	SOUTH PASADENA
State	:	CA
Zip	:	91031-7048
Country	:	US
Telephone Number	:	626-214-8771
Fax Number	:

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

Provider Enumeration Date	:	08/19/2025
Last Update Date	:	08/19/2025

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