Provider Demographics
NPI:1083692552
Name:MADDOX, MARCUS SAMUEL (SLP)
Entity Type:Individual
Prefix:MR
First Name:MARCUS
Middle Name:SAMUEL
Last Name:MADDOX
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5967 CEDAR LN SW
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-3801
Mailing Address - Country:US
Mailing Address - Phone:678-481-7209
Mailing Address - Fax:678-669-2325
Practice Address - Street 1:5967 CEDAR LN SW
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-3801
Practice Address - Country:US
Practice Address - Phone:678-481-7209
Practice Address - Fax:678-669-2325
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-05
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005885235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA379871475BMedicaid
GA379871475CMedicaid