Provider Demographics
NPI:1689391047
Name:MALTZ, MADISON DIANE
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:DIANE
Last Name:MALTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23842 HAWTHORNE BLVD STE 100-101
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-5929
Mailing Address - Country:US
Mailing Address - Phone:310-292-7923
Mailing Address - Fax:
Practice Address - Street 1:28643 VISTA MADERA
Practice Address - Street 2:
Practice Address - City:RANCHO PALOS VERDES
Practice Address - State:CA
Practice Address - Zip Code:90275-0869
Practice Address - Country:US
Practice Address - Phone:310-292-7923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANAOtherBLUECROSS