Provider Demographics
NPI:1255614889
Name:MADDEN-GRUBB, CORRISSA
Entity type:Individual
Prefix:
First Name:CORRISSA
Middle Name:
Last Name:MADDEN-GRUBB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 REICHERT AVE #507
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94945
Mailing Address - Country:US
Mailing Address - Phone:480-202-3859
Mailing Address - Fax:
Practice Address - Street 1:900 FIFTH AVENUE, SUITE 150;
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901
Practice Address - Country:US
Practice Address - Phone:405-202-3859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-20
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health