Provider Demographics
NPI:1295389187
Name:MADDOX, DANA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:MADDOX
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 ADAMS RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:01267-2928
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25 ADAMS RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSTOWN
Practice Address - State:MA
Practice Address - Zip Code:01267-2928
Practice Address - Country:US
Practice Address - Phone:413-458-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-29
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8854235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA8864OtherMASS DEPARTMENT OF LICENSURE