MEDICARE: BRANDY MADRID LCSW

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	1041C0700X	Clinical Social Worker	66056	CA

General Provider Information

NPI Number	:	1588814057
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDY MADRID LCSW

Provider Business Mailing Address
First Line	:	5538 UNIVERSITY AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92105-2307
Country	:	US
Telephone Number	:	619-487-9201
Fax Number	:	619-487-9212

Provider Business Practice Location Address
First Line	:	1250 6TH AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92101-4300
Country	:	US
Telephone Number	:	619-487-9201
Fax Number	:	619-487-9212

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

Provider Enumeration Date	:	09/22/2008
Last Update Date	:	03/01/2016

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