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General NPI Number Information
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NPI Number | 1174295653
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Entity Type | Individual
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Provider Name | RYAN MICHAEL MADDOCK MSW, LICSW
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Gender | Male
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Dates
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Enumeration Date | 10/02/2021
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Last Update Date | 10/02/2021
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Provider Practice Location Address
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Address Line | 1831 2ND ST NE UNIT 407
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City | WASHINGTON
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State | DC
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Zip | 20002-1596
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Country | US
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Telephone | 724-518-1312
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Fax |
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Provider Business Mailing Address
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Address Line | 1831 2ND ST NE UNIT 407
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City | WASHINGTON
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State | DC
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Zip | 20002-1596
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Country | US
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Telephone | 724-518-1312
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LC50079172
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License Number State | DC
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