Provider Demographics
NPI:1154616407
Name:MADDOX, CRAIG EDWARD
Entity type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:EDWARD
Last Name:MADDOX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 WOODSWORTH CLOSE
Mailing Address - Street 2:
Mailing Address - City:RED DEER
Mailing Address - State:ALBERTA
Mailing Address - Zip Code:T4N 5L9
Mailing Address - Country:CA
Mailing Address - Phone:530-320-9864
Mailing Address - Fax:
Practice Address - Street 1:46 NICHOLS ST
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-3275
Practice Address - Country:US
Practice Address - Phone:802-775-2941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT072.0078254225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist