Provider Demographics
NPI:1396221198
Name:MADDOX, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:MADDOX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13909 PUERTO DR
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-2551
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1635 POPPS FERRY RD STE D
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-2312
Practice Address - Country:US
Practice Address - Phone:228-207-0725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-14
Last Update Date:2018-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor