Healthcare Provider Details

I. General information

NPI: 1093904260
Provider Name (Legal Business Name): SAMUEL JERMAINE MADDOX PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2007
Last Update Date: 10/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1777 NORTHEAST EXPY NE SUITE 175
ATLANTA GA
30329-2480
US

IV. Provider business mailing address

1777 NORTHEAST EXPY NE SUITE 175
ATLANTA GA
30329-2480
US

V. Phone/Fax

Practice location:
  • Phone: 678-523-0969
  • Fax: 770-788-7662
Mailing address:
  • Phone: 678-523-0969
  • Fax: 770-788-7662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY002983
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY002983
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberPSY002983
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License NumberPSY002983
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: