Provider Demographics
NPI:1891303327
Name:MADDOX, DARA
Entity Type:Individual
Prefix:
First Name:DARA
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 1:1506 SEABREEZE LN
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-2030
Mailing Address - Country:US
Mailing Address - Phone:321-208-3986
Mailing Address - Fax:
Practice Address - Street 1:1506 SEABREEZE LN
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-2030
Practice Address - Country:US
Practice Address - Phone:321-208-3986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLADC-004887-2014OtherFLORIDA CERTIFICATION BOARD