Provider Demographics
NPI:1285962118
Name:MADDOCKS, MARY (LPC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MADDOCKS
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 1:4555 W SCHROEDER DR
Mailing Address - Street 2:SUITE 170
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53223-1475
Mailing Address - Country:US
Mailing Address - Phone:414-365-3210
Mailing Address - Fax:
Practice Address - Street 1:561 N 15TH ST
Practice Address - Street 2:ROOM 171A
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-2237
Practice Address - Country:US
Practice Address - Phone:414-288-4556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-04
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4247-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional