Provider Demographics
NPI:1104553288
Name:BAILEY, MADISON BRENNA (PSYD)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:BRENNA
Last Name:BAILEY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 MAIN ST
Mailing Address - Street 2:PO BOX 57
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-2937
Mailing Address - Country:US
Mailing Address - Phone:480-735-4587
Mailing Address - Fax:
Practice Address - Street 1:150 MUIR RD # 116
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553-4668
Practice Address - Country:US
Practice Address - Phone:925-897-8212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-08
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY34141103TC0700X, 103TH0004X
390200000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103T00000XBehavioral Health & Social Service ProvidersPsychologist