Provider Demographics
NPI:1073281804
Name:MADDOX, ENRICKA VICTORIA (LPC)
Entity type:Individual
Prefix:
First Name:ENRICKA
Middle Name:VICTORIA
Last Name:MADDOX
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 TABOR TRCE
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30054-4049
Mailing Address - Country:US
Mailing Address - Phone:404-453-3680
Mailing Address - Fax:
Practice Address - Street 1:1500 KLONDIKE RD SW STE A103
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-5115
Practice Address - Country:US
Practice Address - Phone:770-609-1936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008094101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional