Provider Demographics
NPI:1366133613
Name:MADRIGAL, VANESSA MARIE
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:MARIE
Last Name:MADRIGAL
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 1:902 S MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-3427
Mailing Address - Country:US
Mailing Address - Phone:626-506-9799
Mailing Address - Fax:
Practice Address - Street 1:902 S MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-3427
Practice Address - Country:US
Practice Address - Phone:626-506-9799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-17
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT147756106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist