Basic Information
| Provider Information | |||||||||
| NPI: | 1922432319 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IXTA MADERA | ||||||||
| FirstName: | ELLIANA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 509 E ROSECRANS AVE | ||||||||
| Address2: | |||||||||
| City: | COMPTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902212056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2133855100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 509 E ROSECRANS AVE | ||||||||
| Address2: | |||||||||
| City: | COMPTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2133855100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2013 | ||||||||
| LastUpdateDate: | 08/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 104100000X | 63242 | CA | N | Behavioral Health & Social Service Providers | Social Worker | 101YM0800X | 63242 | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 103120 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.