Provider Demographics
NPI:1437902590
Name:MADDOX, MIRANDA BROOKE
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:BROOKE
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 1:928 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:OAK HILL
Mailing Address - State:WV
Mailing Address - Zip Code:25901-2409
Mailing Address - Country:US
Mailing Address - Phone:304-640-1454
Mailing Address - Fax:
Practice Address - Street 1:4234 GRANDVIEW RD
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:WV
Practice Address - Zip Code:25813-9105
Practice Address - Country:US
Practice Address - Phone:304-573-0163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-09
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker