Provider Demographics
NPI:1366802902
Name:MADRIGAL, DESIREE E
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:E
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 1:5101 MARKET ST. SUITE 2100
Mailing Address - Street 2:ATTENTION: ECC
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92114
Mailing Address - Country:US
Mailing Address - Phone:619-850-7964
Mailing Address - Fax:
Practice Address - Street 1:5101 MARKET ST STE 2100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92114-2224
Practice Address - Country:US
Practice Address - Phone:619-508-7964
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-24
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW1164861041C0700X
CAASW75872101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical