Provider Demographics
NPI:1629421417
Name:MADDOX, WILLIAM JR (LSW, LICDC)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:MADDOX
Suffix:JR
Gender:M
Credentials:LSW, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8411 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44105-3932
Mailing Address - Country:US
Mailing Address - Phone:216-206-5201
Mailing Address - Fax:216-441-3637
Practice Address - Street 1:8411 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44105
Practice Address - Country:US
Practice Address - Phone:216-206-5201
Practice Address - Fax:216-441-3637
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-18
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS1302263104100000X
OHI141146101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker