Provider Demographics
NPI:1336619485
Name:MADDOX, KHIRY SHAE (MED, BCBA, LBA)
Entity Type:Individual
Prefix:MR
First Name:KHIRY
Middle Name:SHAE
Last Name:MADDOX
Suffix:
Gender:M
Credentials:MED, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:2427 RUSSELLVILLE RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-3980
Practice Address - Country:US
Practice Address - Phone:270-936-7472
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2018-12-03
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY245478103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-18-32527OtherBCBA CERTIFICATE