MEDICARE: WIILAM J MADDOCK CACIII

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TA0400X	Addiction (Substance Use Disorder) Psychologist	ACC-634	CO

General Provider Information

NPI Number	:	1457677957
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WIILAM J MADDOCK CACIII

Provider Business Mailing Address
First Line	:	990 BANNOCK ST
Second Line	:	MC 7782
City	:	DENVER
State	:	CO
Zip	:	80204-4028
Country	:	US
Telephone Number	:	303-436-3563
Fax Number	:	303-436-3500

Provider Business Practice Location Address
First Line	:	990 BANNOCK ST
Second Line	:	MC 7782
City	:	DENVER
State	:	CO
Zip	:	80204-4028
Country	:	US
Telephone Number	:	720-956-2394
Fax Number	:	720-956-2533

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/09/2010
Last Update Date	:	04/09/2010

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