MEDICARE: MRS. KATRINA NICOLE MADDOX LPC

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	LPC016950	GA
2	101YM0800X	Mental Health Counselor	20131571309	NV

General Provider Information

NPI Number	:	1699191346
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KATRINA NICOLE MADDOX LPC

Provider Business Mailing Address
First Line	:	743 IRELAND LN
Second Line	:
City	:	DALLAS
State	:	GA
Zip	:	30132-0073
Country	:	US
Telephone Number	:	404-295-3757
Fax Number	:

Provider Business Practice Location Address
First Line	:	2500 DALLAS HWY SW STE 202-1033
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30064-2567
Country	:	US
Telephone Number	:	404-295-3757
Fax Number	:

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

Provider Enumeration Date	:	03/05/2014
Last Update Date	:	06/18/2026

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