Provider Demographics
NPI:1285292540
Name:MADDOCK, KATELYN M (LLMSW)
Entity type:Individual
Prefix:MISS
First Name:KATELYN
Middle Name:M
Last Name:MADDOCK
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48130 ROYAL POINTE DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-5466
Mailing Address - Country:US
Mailing Address - Phone:734-664-3345
Mailing Address - Fax:
Practice Address - Street 1:48130 ROYAL POINTE DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-5466
Practice Address - Country:US
Practice Address - Phone:734-664-3345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011014621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty