Provider Demographics
NPI:1679138267
Name:MADDOX, TARNESHIA S
Entity Type:Individual
Prefix:
First Name:TARNESHIA
Middle Name:S
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 1:1482 UNDERWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:GA
Mailing Address - Zip Code:31087-9612
Mailing Address - Country:US
Mailing Address - Phone:478-234-9283
Mailing Address - Fax:
Practice Address - Street 1:1482 UNDERWOOD RD
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:GA
Practice Address - Zip Code:31087-9612
Practice Address - Country:US
Practice Address - Phone:478-234-9283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-08
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA05Medicaid