Provider Demographics
NPI:1194946582
Name:MADSEN, JOHN THOMAS (CADC II)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:THOMAS
Last Name:MADSEN
Suffix:
Gender:M
Credentials:CADC II
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:440 HENDERSON ST
Mailing Address - Street 2:SIUTE C
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-7374
Mailing Address - Country:US
Mailing Address - Phone:530-273-9541
Mailing Address - Fax:530-273-7740
Practice Address - Street 1:440 HENDERSON ST
Practice Address - Street 2:SIUTE C
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-7374
Practice Address - Country:US
Practice Address - Phone:530-273-9541
Practice Address - Fax:530-273-7740
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
324500000X
CAA8539205101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility