Provider Demographics
NPI:1720048986
Name:MADDOCK, MARY L (AUD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:L
Last Name:MADDOCK
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 SPRING CREEK LN
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28411-7647
Mailing Address - Country:US
Mailing Address - Phone:910-620-2083
Mailing Address - Fax:
Practice Address - Street 1:150 SPRING CREEK LN
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28411-7647
Practice Address - Country:US
Practice Address - Phone:910-620-2083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1790231HA2400X, 231HA2500X, 237600000X, 231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No231HA2400XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Practitioner
No231HA2500XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Supplier
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7412368Medicaid
NC7001525Medicaid
NC130C7OtherBLUE CROSS BLUE SHIELD
NC7412368Medicaid