Basic Information
| Provider Information | |||||||||
| NPI: | 1568768158 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MADDOX | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | MENTAL HEALTH TECH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8400 LOUISIANA ST | ||||||||
| Address2: | |||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464106385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197571932 | ||||||||
| FaxNumber: | 2197571950 | ||||||||
| Practice Location | |||||||||
| Address1: | 3903 INDIANAPOLIS BLVD | ||||||||
| Address2: | |||||||||
| City: | EAST CHICAGO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463122555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2194731350 | ||||||||
| FaxNumber: | 2193926998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2011 | ||||||||
| LastUpdateDate: | 01/31/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.