Provider Demographics
NPI:1427935329
Name:MAMMEN, MADISON SOPHIA-LORRAINE
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:SOPHIA-LORRAINE
Last Name:MAMMEN
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 1:2256 62ND AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95822-4631
Mailing Address - Country:US
Mailing Address - Phone:279-786-1028
Mailing Address - Fax:
Practice Address - Street 1:2256 62ND AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95822-4631
Practice Address - Country:US
Practice Address - Phone:279-786-1028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-20
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst