Provider Demographics
NPI:1609586338
Name:MADDIX THERAPY ALLIANCE
Entity Type:Organization
Organization Name:MADDIX THERAPY ALLIANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TIESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MADDIX
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:917-667-0462
Mailing Address - Street 1:2909 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06604-1328
Mailing Address - Country:US
Mailing Address - Phone:917-667-0462
Mailing Address - Fax:
Practice Address - Street 1:595 E 59TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-1301
Practice Address - Country:US
Practice Address - Phone:718-864-1135
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty