Healthcare Provider Details

I. General information

NPI: 1457677957
Provider Name (Legal Business Name): WIILAM J MADDOCK CACIII
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2010
Last Update Date: 04/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

990 BANNOCK ST MC 7782
DENVER CO
80204-4028
US

IV. Provider business mailing address

990 BANNOCK ST MC 7782
DENVER CO
80204-4028
US

V. Phone/Fax

Practice location:
  • Phone: 720-956-2394
  • Fax: 720-956-2533
Mailing address:
  • Phone: 303-436-3563
  • Fax: 303-436-3500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberACC-634
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: