Provider Demographics
NPI:1720105703
Name:GADDIE, MAURICE RANDOLPH (LBSW)
Entity Type:Individual
Prefix:
First Name:MAURICE
Middle Name:RANDOLPH
Last Name:GADDIE
Suffix:
Gender:M
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8840 2ND AVE
Mailing Address - Street 2:APT. 202
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-1769
Mailing Address - Country:US
Mailing Address - Phone:313-516-7773
Mailing Address - Fax:
Practice Address - Street 1:5555 CONNER ST
Practice Address - Street 2:SUITE 1000 SOUTH
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213-3448
Practice Address - Country:US
Practice Address - Phone:313-347-2070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802081421104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker