Provider Demographics
NPI:1093288359
Name:MADDOX, JOHNNIE RUTH (CDCA)
Entity Type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:RUTH
Last Name:MADDOX
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3743 GREENBAY DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-2020
Mailing Address - Country:US
Mailing Address - Phone:937-742-7006
Mailing Address - Fax:
Practice Address - Street 1:732 BECKMAN ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45410-2165
Practice Address - Country:US
Practice Address - Phone:937-253-1680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-09
Last Update Date:2024-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician