Provider Demographics
NPI:1467201145
Name:MADDOX, DINA LOUISE (LMT)
Entity type:Individual
Prefix:MS
First Name:DINA
Middle Name:LOUISE
Last Name:MADDOX
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1503 WOODBRIDGE RD APT 1G
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60436-1389
Mailing Address - Country:US
Mailing Address - Phone:623-640-9330
Mailing Address - Fax:
Practice Address - Street 1:1503 WOODBRIDGE RD APT 1G
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60436-1389
Practice Address - Country:US
Practice Address - Phone:623-640-9330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-15306225700000X
IL227022072225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist