Provider Demographics
NPI:1053981373
Name:MADDOX, MELANIE (MA)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:MADDOX
Suffix:
Gender:
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 S 300 W
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84101-1217
Mailing Address - Country:US
Mailing Address - Phone:801-467-6060
Mailing Address - Fax:
Practice Address - Street 1:3010 WILSHIRE BLVD # 354
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-1103
Practice Address - Country:US
Practice Address - Phone:213-761-4246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-29
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA116137101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program