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General NPI Number Information
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NPI Number | 1609586338
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Entity Type | Organization
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Legal Business Name | MADDIX THERAPY ALLIANCE
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Dates
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Enumeration Date | 12/05/2022
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Last Update Date | 12/05/2022
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Provider Practice Location Address
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Address Line | 595 E 59TH ST
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City | BROOKLYN
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State | NY
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Zip | 11234-1301
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Country | US
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Telephone | 718-864-1135
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Fax |
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Provider Business Mailing Address
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Address Line | 2909 PARK AVE
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City | BRIDGEPORT
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State | CT
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Zip | 06604-1328
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Country | US
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Telephone | 917-667-0462
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Fax |
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Authorized Official
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Title or Position | PSYCHOLOGIST
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Name | DR. TIESHA MADDIX
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Credential | PSYD
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Telephone | 917-667-0462
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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