Provider Demographics
NPI:1417083643
Name:MADDOX, DRETONA TENESE (RN, PHN, LCSW)
Entity Type:Individual
Prefix:MRS
First Name:DRETONA
Middle Name:TENESE
Last Name:MADDOX
Suffix:
Gender:F
Credentials:RN, PHN, LCSW
Other - Prefix:
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Mailing Address - Street 1:1410 3RD ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-3482
Mailing Address - Country:US
Mailing Address - Phone:909-471-0697
Mailing Address - Fax:760-302-7607
Practice Address - Street 1:1410 3RD ST
Practice Address - Street 2:SUITE 2
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-3482
Practice Address - Country:US
Practice Address - Phone:909-471-0697
Practice Address - Fax:760-302-7607
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA618042163W00000X, 163WC0400X, 163WC1500X, 163WC1600X, 163WM0102X, 163WN0002X, 163WN0003X, 163WN1003X, 163WP0200X, 163WP0807X, 163WP0807X, 163W00000X
CA813371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163WC1600XNursing Service ProvidersRegistered NurseContinuing Education/Staff Development
No163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn
No163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care
No163WN0003XNursing Service ProvidersRegistered NurseNeonatal, Low-Risk
No163WN1003XNursing Service ProvidersRegistered NurseNutrition Support
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARVN004760Medicaid
CAEPS016610Medicaid