MEDICARE: DR. MARY GRACE MADRIGAL PHD

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	101YM0800X	Mental Health Counselor
2	103TC0700X	Clinical Psychologist	PSY24917	CA

General Provider Information

NPI Number	:	1740298819
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY GRACE MADRIGAL PHD

Provider Business Mailing Address
First Line	:	PO BOX 5113
Second Line	:
City	:	GARDEN GROVE
State	:	CA
Zip	:	92846-0113
Country	:	US
Telephone Number	:	714-504-8840
Fax Number	:

Provider Business Practice Location Address
First Line	:	18811 HUNTINGTON ST STE 200
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92648-6003
Country	:	US
Telephone Number	:	714-504-8840
Fax Number	:

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

Provider Enumeration Date	:	08/04/2006
Last Update Date	:	03/30/2012

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