MEDICARE: DEENA MARIE MADRID LMFT

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	104174	CA

General Provider Information

NPI Number	:	1720415789
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEENA MARIE MADRID LMFT

Provider Business Mailing Address
First Line	:	325 W WASHINGTON ST STE 2
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-1946
Country	:	US
Telephone Number	:	956-405-2831
Fax Number	:

Provider Business Practice Location Address
First Line	:	1625 NEWTON AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92113-1012
Country	:	US
Telephone Number	:	956-405-2831
Fax Number	:

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

Provider Enumeration Date	:	10/03/2013
Last Update Date	:	02/20/2025

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