Healthcare Provider Details

I. General information

NPI: 1154119212
Provider Name (Legal Business Name): CARL H MADDOX CCAR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2025
Last Update Date: 04/29/2025
Certification Date: 04/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1044 GILBERT ST
FLINT MI
48532-3527
US

IV. Provider business mailing address

31581 GRATIOT AVE
ROSEVILLE MI
48066-4528
US

V. Phone/Fax

Practice location:
  • Phone: 810-422-9406
  • Fax: 810-733-7623
Mailing address:
  • Phone: 586-783-4802
  • Fax: 586-783-4805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number195293
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: