Healthcare Provider Details

I. General information

NPI: 1699191346
Provider Name (Legal Business Name): KATRINA NICOLE MADDOX LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2014
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 DALLAS HWY SW STE 202-1033
MARIETTA GA
30064-2567
US

IV. Provider business mailing address

743 IRELAND LN
DALLAS GA
30132-0073
US

V. Phone/Fax

Practice location:
  • Phone: 404-295-3757
  • Fax:
Mailing address:
  • Phone: 404-295-3757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC016950
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number20131571309
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: