Provider Demographics
NPI:1689401200
Name:MABREY, MADISON BROOK
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:BROOK
Last Name:MABREY
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 1:451 S CARROLL AVE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95215-5208
Mailing Address - Country:US
Mailing Address - Phone:916-385-1719
Mailing Address - Fax:
Practice Address - Street 1:451 S CARROLL AVE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95215-5208
Practice Address - Country:US
Practice Address - Phone:916-385-1719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician