Healthcare Provider Details

I. General information

NPI: 1073680195
Provider Name (Legal Business Name): MISS GWEN ELLEN MADDIX
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 11/19/2025
Certification Date: 11/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3436 W MALAPAI
PHX AZ
85051
US

IV. Provider business mailing address

4232 W WALTANN LN
PHOENIX AZ
85053-3772
US

V. Phone/Fax

Practice location:
  • Phone: 602-570-5742
  • Fax:
Mailing address:
  • Phone: 602-570-5742
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: