Basic Information
| Provider Information | |||||||||
| NPI: | 1225214612 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MADDOCKS | ||||||||
| FirstName: | SUZANNE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 285 W 800 S | ||||||||
| Address2: | |||||||||
| City: | ROOSEVELT | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840663707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357256300 | ||||||||
| FaxNumber: | 4357256325 | ||||||||
| Practice Location | |||||||||
| Address1: | 285 W 800 S | ||||||||
| Address2: | |||||||||
| City: | ROOSEVELT | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840663707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357256300 | ||||||||
| FaxNumber: | 4357256325 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2008 | ||||||||
| LastUpdateDate: | 06/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 5318390-3501 | UT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.