MEDICARE: ASHLEY RENEE MADDOCK

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1215789482
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ASHLEY RENEE MADDOCK

Provider Business Mailing Address
First Line	:	16609 E DESMET CT APT D204
Second Line	:
City	:	SPOKANE VALLEY
State	:	WA
Zip	:	99216-3558
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	16609 E DESMET CT APT D204
Second Line	:
City	:	SPOKANE VALLEY
State	:	WA
Zip	:	99216-3558
Country	:	US
Telephone Number	:	920-517-7604
Fax Number	:

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

Provider Enumeration Date	:	04/02/2024
Last Update Date	:	04/02/2024

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Directions to “ ASHLEY RENEE MADDOCK ” Practice Location

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