Provider Demographics
NPI:1346748449
Name:MADDOX, AKIA SHAUAAN
Entity Type:Individual
Prefix:
First Name:AKIA
Middle Name:SHAUAAN
Last Name:MADDOX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2325 BROOKSTONE CENTRE PKWY
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-4500
Mailing Address - Country:US
Mailing Address - Phone:706-653-6841
Mailing Address - Fax:706-653-7843
Practice Address - Street 1:2325 BROOKSTONE CENTRE PKWY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-4500
Practice Address - Country:US
Practice Address - Phone:706-653-6841
Practice Address - Fax:706-653-7843
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-24
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC009409101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003213855AMedicaid