Provider Demographics
NPI:1790935161
Name:MADDOX, ANNIE LAURIE (LCSW)
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:LAURIE
Last Name:MADDOX
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 E STEELE ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-3908
Mailing Address - Country:US
Mailing Address - Phone:321-765-3102
Mailing Address - Fax:
Practice Address - Street 1:3222 CORRINE DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-2217
Practice Address - Country:US
Practice Address - Phone:407-462-0845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-23
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW52081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical