Provider Demographics
NPI:1659088870
Name:MADDOX, ANTASIA (LLMSW)
Entity Type:Individual
Prefix:
First Name:ANTASIA
Middle Name:
Last Name:MADDOX
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 PEARL ST STE 503
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-2663
Mailing Address - Country:US
Mailing Address - Phone:734-620-1935
Mailing Address - Fax:
Practice Address - Street 1:124 PEARL ST STE 503
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-2663
Practice Address - Country:US
Practice Address - Phone:734-620-1936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-28
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851104276101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health