Provider Demographics
NPI:1477944585
Name:MADDOX, LACORTNEY (LISW-CP, LCSW)
Entity Type:Individual
Prefix:
First Name:LACORTNEY
Middle Name:
Last Name:MADDOX
Suffix:
Gender:F
Credentials:LISW-CP, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3092 TSUE LN
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-4952
Mailing Address - Country:US
Mailing Address - Phone:910-382-3889
Mailing Address - Fax:910-304-6651
Practice Address - Street 1:3092 TSUE LN
Practice Address - Street 2:
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-4952
Practice Address - Country:US
Practice Address - Phone:910-382-3889
Practice Address - Fax:910-304-6651
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-11
Last Update Date:2023-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA914211041C0700X
HI48621041C0700X, 1041C0700X
SC134311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical