Provider Demographics
NPI:1861093643
Name:KINGSBURY, MADISON KATE
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:KATE
Last Name:KINGSBURY
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 1:3055 W CANYON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-5423
Mailing Address - Country:US
Mailing Address - Phone:858-254-6876
Mailing Address - Fax:
Practice Address - Street 1:1010 TURQUOISE ST STE 303
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-1268
Practice Address - Country:US
Practice Address - Phone:619-800-4036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122342106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist