Provider Demographics
NPI:1699191346
Name:MADDOX, KATRINA NICOLE
Entity Type:Individual
Prefix:MRS
First Name:KATRINA
Middle Name:NICOLE
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 1:728 S EAST AVE
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360-5810
Mailing Address - Country:US
Mailing Address - Phone:856-305-5936
Mailing Address - Fax:
Practice Address - Street 1:728 S EAST AVE
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-5810
Practice Address - Country:US
Practice Address - Phone:856-305-5936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-05
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV20131571309101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health