1740597012 NPI number — MRS. HELEN PHAEDRA MADER M.A., B.C.B.A.

Table of content: MRS. HELEN PHAEDRA MADER M.A., B.C.B.A. (NPI 1740597012)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740597012 NPI number — MRS. HELEN PHAEDRA MADER M.A., B.C.B.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MADER
Provider First Name:
HELEN
Provider Middle Name:
PHAEDRA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.A., B.C.B.A.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740597012
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18726 S WESTERN AVE
Provider Second Line Business Mailing Address:
SUITE 408
Provider Business Mailing Address City Name:
GARDENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90248-3813
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-856-0800
Provider Business Mailing Address Fax Number:
310-324-3134

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18726 S WESTERN AVE
Provider Second Line Business Practice Location Address:
SUITE 408
Provider Business Practice Location Address City Name:
GARDENA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90248-3813
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-856-0800
Provider Business Practice Location Address Fax Number:
310-324-3134
Provider Enumeration Date:
09/08/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  1-04-1503 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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