Provider Demographics
NPI:1861836082
Name:MADDOX, SHIRLYNN
Entity Type:Individual
Prefix:
First Name:SHIRLYNN
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 1:524 E. CLEAVLAND BLVD, SUITE #230
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:524 CLEVELAND BLVD STE 230
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4080
Practice Address - Country:US
Practice Address - Phone:208-454-9054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-18
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW 313451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical