Provider Demographics
NPI:1205950755
Name:MADDOX, MARTHA C (MFT)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:C
Last Name:MADDOX
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7136 HASKELL AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-4112
Mailing Address - Country:US
Mailing Address - Phone:818-773-3629
Mailing Address - Fax:
Practice Address - Street 1:7136 HASKELL AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-4112
Practice Address - Country:US
Practice Address - Phone:818-773-3629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC29630106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist