Provider Demographics
NPI:1194548321
Name:MACE, MADELINE (AMFT)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:MACE
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 67
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-0067
Mailing Address - Country:US
Mailing Address - Phone:909-255-9156
Mailing Address - Fax:
Practice Address - Street 1:104 E OLIVE AVE STE 201
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-5255
Practice Address - Country:US
Practice Address - Phone:949-478-0235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-06
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT150397106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist