Provider Demographics
NPI:1144932492
Name:MADERO, JAMES NICHOLAS (PHD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:NICHOLAS
Last Name:MADERO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13233 BLACK MOUNTAIN ROAD, #200
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129
Mailing Address - Country:US
Mailing Address - Phone:858-442-4282
Mailing Address - Fax:
Practice Address - Street 1:13368 DARVIEW LN
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92129-2388
Practice Address - Country:US
Practice Address - Phone:858-442-4282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY9558103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical