MEDICARE: LETITIA ELIZABETH MADDOCK LVN

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1336337377
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LETITIA ELIZABETH MADDOCK LVN

Provider Business Mailing Address
First Line	:	1260 MORENA BLVD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92110-3889
Country	:	US
Telephone Number	:	619-398-0355
Fax Number	:

Provider Business Practice Location Address
First Line	:	1260 MORENA BLVD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92110-3889
Country	:	US
Telephone Number	:	619-398-0355
Fax Number	:

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

Provider Enumeration Date	:	10/03/2007
Last Update Date	:	10/03/2007

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