Provider Demographics
NPI:1568066652
Name:MADDOX, TYSHEIRA (LCSW)
Entity Type:Individual
Prefix:
First Name:TYSHEIRA
Middle Name:
Last Name:MADDOX
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 CHESTNUT ST STE 2
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-2700
Mailing Address - Country:US
Mailing Address - Phone:267-752-9421
Mailing Address - Fax:888-892-2862
Practice Address - Street 1:7113 MONTAGUE STREET
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19135
Practice Address - Country:US
Practice Address - Phone:267-752-9421
Practice Address - Fax:888-892-2862
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW137621104100000X
PACW0234921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker