Healthcare Provider Details

I. General information

NPI: 1952823551
Provider Name (Legal Business Name): MICHELLE LAURA MADDEX LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2017
Last Update Date: 01/09/2023
Certification Date: 01/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 DIMOCK ST
ROXBURY MA
02119-1208
US

IV. Provider business mailing address

240 SHOTWELL ST
SAN FRANCISCO CA
94110-1323
US

V. Phone/Fax

Practice location:
  • Phone: 617-442-8800
  • Fax: 617-541-5472
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW77284
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number125585
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: