Provider Demographics
NPI:1154843514
Name:MADDOX, LOREAL (LLBSW)
Entity Type:Individual
Prefix:
First Name:LOREAL
Middle Name:
Last Name:MADDOX
Suffix:
Gender:F
Credentials:LLBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-4825
Mailing Address - Country:US
Mailing Address - Phone:313-348-6025
Mailing Address - Fax:
Practice Address - Street 1:2925 RUSSELL
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207
Practice Address - Country:US
Practice Address - Phone:313-348-6025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68020893751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical