Provider Demographics
NPI:1134711955
Name:MADDOX, STASIA
Entity type:Individual
Prefix:
First Name:STASIA
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 1:4271 HIGH STAKES CIR APT 104
Mailing Address - Street 2:
Mailing Address - City:PARKTON
Mailing Address - State:NC
Mailing Address - Zip Code:28371-9097
Mailing Address - Country:US
Mailing Address - Phone:910-705-0078
Mailing Address - Fax:
Practice Address - Street 1:1018 N BRAGG BLVD
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:NC
Practice Address - Zip Code:28390-3316
Practice Address - Country:US
Practice Address - Phone:910-295-2609
Practice Address - Fax:800-948-6061
Is Sole Proprietor?:No
Enumeration Date:2021-02-04
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician