MEDICARE: JUSTIN MADDOX BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-16-22928

General Provider Information

NPI Number	:	1205405933
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTIN MADDOX BCBA

Provider Business Mailing Address
First Line	:	218 EAST RD
Second Line	:
City	:	HAMPSTEAD
State	:	NH
Zip	:	03841-2305
Country	:	US
Telephone Number	:	603-329-5311
Fax Number	:

Provider Business Practice Location Address
First Line	:	218 EAST RD
Second Line	:
City	:	HAMPSTEAD
State	:	NH
Zip	:	03841-2305
Country	:	US
Telephone Number	:	603-329-5311
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2021
Last Update Date	:	03/07/2022

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