Healthcare Provider Details

I. General information

NPI: 1417083643
Provider Name (Legal Business Name): DRETONA TENESE MADDOX RN, PHN, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 3RD ST SUITE 2
RIVERSIDE CA
92507-3482
US

IV. Provider business mailing address

1410 3RD ST SUITE 2
RIVERSIDE CA
92507-3482
US

V. Phone/Fax

Practice location:
  • Phone: 909-471-0697
  • Fax: 760-302-7607
Mailing address:
  • Phone: 909-471-0697
  • Fax: 760-302-7607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number618042
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number618042
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number618042
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code163WC1600X
TaxonomyContinuing Education/Staff Development Registered Nurse
License Number618042
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number618042
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number618042
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code163WN0003X
TaxonomyLow-Risk Neonatal Registered Nurse
License Number618042
License Number StateCA
# 8
Primary TaxonomyN
Taxonomy Code163WN1003X
TaxonomyNutrition Support Registered Nurse
License Number618042
License Number StateCA
# 9
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number618042
License Number StateCA
# 10
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number618042
License Number StateCA
# 11
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number81337
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: