Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 104100000X | Social Worker | 68030385984 | MI |
NPI | 1003259193 |
---|---|
Provider Name | Tracy Maddox |
First Address | Lansing, MI 48910-6818 |
Second Address | Lansing, MI 48911-3800 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/04/2013 |
Last Update Date | 09/04/2013 |