Provider Demographics
NPI:1396221842
Name:MADDOX, LEAH JOY
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:JOY
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 1:9963 MALLOW ST
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-4218
Mailing Address - Country:US
Mailing Address - Phone:323-313-7659
Mailing Address - Fax:
Practice Address - Street 1:9963 MALLOW ST
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4218
Practice Address - Country:US
Practice Address - Phone:323-313-7659
Practice Address - Fax:703-257-7609
Is Sole Proprietor?:No
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst