Healthcare Provider Details

I. General information

NPI: 1790889475
Provider Name (Legal Business Name): NANCY DEANE GOOD MADDOX MA LSPE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 01/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6144 CUMBERLAND GAP PARKWAY SUITE 2
HARROGATE TN
37752
US

IV. Provider business mailing address

PO BOX 1604
NEW TAZEWELL TN
37824-1604
US

V. Phone/Fax

Practice location:
  • Phone: 423-626-6352
  • Fax:
Mailing address:
  • Phone: 423-626-6352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License NumberSPE 1475
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: