Provider Demographics
NPI:1174295653
Name:MADDOCK, RYAN MICHAEL (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:MICHAEL
Last Name:MADDOCK
Suffix:
Gender:M
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1831 2ND ST NE UNIT 407
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-1596
Mailing Address - Country:US
Mailing Address - Phone:724-518-1312
Mailing Address - Fax:
Practice Address - Street 1:1831 2ND ST NE UNIT 407
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-1596
Practice Address - Country:US
Practice Address - Phone:724-518-1312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-02
Last Update Date:2021-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC500791721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical