Provider Demographics
NPI:1265268635
Name:DIAS, MADALENA COSTA
Entity type:Individual
Prefix:
First Name:MADALENA
Middle Name:COSTA
Last Name:DIAS
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 1:1925 WINCHESTER BLVD STE 204
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-1038
Mailing Address - Country:US
Mailing Address - Phone:408-508-3611
Mailing Address - Fax:
Practice Address - Street 1:1925 WINCHESTER BLVD STE 204
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-1038
Practice Address - Country:US
Practice Address - Phone:408-508-3611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-11
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA145923101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health