Healthcare Provider Details

I. General information

NPI: 1568768158
Provider Name (Legal Business Name): MICHAEL MADDOX MENTAL HEALTH TECH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2011
Last Update Date: 01/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3903 INDIANAPOLIS BLVD
EAST CHICAGO IN
46312-2555
US

IV. Provider business mailing address

8400 LOUISIANA ST
MERRILLVILLE IN
46410-6385
US

V. Phone/Fax

Practice location:
  • Phone: 219-473-1350
  • Fax: 219-392-6998
Mailing address:
  • Phone: 219-757-1932
  • Fax: 219-757-1950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: