Healthcare Provider Details

I. General information

NPI: 1720048986
Provider Name (Legal Business Name): MARY L MADDOCK AU.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 SPRING CREEK LN
WILMINGTON NC
28411-7647
US

IV. Provider business mailing address

150 SPRING CREEK LN
WILMINGTON NC
28411-7647
US

V. Phone/Fax

Practice location:
  • Phone: 910-620-2083
  • Fax:
Mailing address:
  • Phone: 910-620-2083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number1790
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code231HA2400X
TaxonomyAssistive Technology Practitioner Audiologist
License Number1790
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code231HA2500X
TaxonomyAssistive Technology Supplier Audiologist
License Number1790
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number1790
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: