Provider Demographics
NPI:1427441260
Name:MADRID, AMANDA K (LCSW)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:K
Last Name:MADRID
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:M
Other - Last Name:KUBICEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ACSW
Mailing Address - Street 1:252 16TH PL APT C
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-9410
Mailing Address - Country:US
Mailing Address - Phone:319-360-5995
Mailing Address - Fax:
Practice Address - Street 1:12440 E FIRESTONE BLVD
Practice Address - Street 2:SUITE 3020
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-9331
Practice Address - Country:US
Practice Address - Phone:562-864-7821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-17
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81455104100000X
CA37965167G00000X
CA1015021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No167G00000XNursing Service ProvidersLicensed Psychiatric Technician