Provider Demographics
NPI:1316349780
Name:BRIGHTWELL, MADISON (MFT)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:BRIGHTWELL
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1706 VAN HORNE LN
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-4738
Mailing Address - Country:US
Mailing Address - Phone:310-801-9097
Mailing Address - Fax:
Practice Address - Street 1:1706 VAN HORNE LN
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90278-4738
Practice Address - Country:US
Practice Address - Phone:310-801-9097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-17
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA82283106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist