Provider Demographics
NPI:1184382533
Name:MADDOCKS, EMMA K
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:K
Last Name:MADDOCKS
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 1:4605 BRUENING DR
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44134-4639
Mailing Address - Country:US
Mailing Address - Phone:740-434-3738
Mailing Address - Fax:
Practice Address - Street 1:1730 W 25TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44113-3108
Practice Address - Country:US
Practice Address - Phone:216-696-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-02
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD.09481133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered