Healthcare Provider Details

I. General information

NPI: 1649188830
Provider Name (Legal Business Name): TAJAMYAH MADDOX
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TAJ MADDOX

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 MACON ST STE 5
MCDONOUGH GA
30253-3221
US

IV. Provider business mailing address

906 BIG OAK CT
MCDONOUGH GA
30253-8244
US

V. Phone/Fax

Practice location:
  • Phone: 470-220-0621
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: