Provider Demographics
NPI:1639545593
Name:MADDOX, LISLINE
Entity Type:Individual
Prefix:
First Name:LISLINE
Middle Name:
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 1:19 HEARTHSTONE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH EASTON
Mailing Address - State:MA
Mailing Address - Zip Code:02375-1350
Mailing Address - Country:US
Mailing Address - Phone:508-369-2412
Mailing Address - Fax:
Practice Address - Street 1:20 EASTBROOK RD
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-2075
Practice Address - Country:US
Practice Address - Phone:781-302-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-14
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor