Provider Demographics
NPI:1912379918
Name:MADDOX, WILLIE
Entity Type:Individual
Prefix:
First Name:WILLIE
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 1:10245 S MARYLAND PKWY UNIT 1195
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89183-4058
Mailing Address - Country:US
Mailing Address - Phone:810-447-1977
Mailing Address - Fax:
Practice Address - Street 1:5258 S EASTERN AVE
Practice Address - Street 2:105
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-2326
Practice Address - Country:US
Practice Address - Phone:702-464-5080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-29
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management