Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | PSY002983 | GA |
Y | 103TC0700X | Clinical Psychologist | PSY002983 | GA |
N | 103TC2200X | Clinical Child & Adolescent Psychologist | PSY002983 | GA |
N | 103TF0000X | Family Psychologist | PSY002983 | GA |
N | 103TM1800X | Intellectual & Developmental Disabilities | PSY002983 | GA |
NPI | 1093904260 |
---|---|
Provider Name | Dr. Samuel Jermaine Maddox |
First Address | Atlanta, GA 30329-2480 |
Second Address | Atlanta, GA 30329-2480 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/10/2007 |
Last Update Date | 23/10/2007 |