Provider Demographics
NPI:1093904260
Name:MADDOX, SAMUEL JERMAINE (PHD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:JERMAINE
Last Name:MADDOX
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1777 NORTHEAST EXPY NE
Mailing Address - Street 2:SUITE 175
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2480
Mailing Address - Country:US
Mailing Address - Phone:678-523-0969
Mailing Address - Fax:770-788-7662
Practice Address - Street 1:1777 NORTHEAST EXPY NE
Practice Address - Street 2:SUITE 175
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2480
Practice Address - Country:US
Practice Address - Phone:678-523-0969
Practice Address - Fax:770-788-7662
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002983103TC0700X, 103TC2200X, 103TF0000X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities