Provider Demographics
NPI:1952747099
Name:MADDIX, ANDREA FAYE (COTA/L)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:FAYE
Last Name:MADDIX
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1658 PRIVATE ROAD 3952
Mailing Address - Street 2:
Mailing Address - City:WILLOW WOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45696-8932
Mailing Address - Country:US
Mailing Address - Phone:740-867-4027
Mailing Address - Fax:
Practice Address - Street 1:1658 PRIVATE ROAD 3952
Practice Address - Street 2:
Practice Address - City:WILLOW WOOD
Practice Address - State:OH
Practice Address - Zip Code:45696-8932
Practice Address - Country:US
Practice Address - Phone:740-867-4027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-16
Last Update Date:2013-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVC1682225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist