Provider Demographics
NPI:1679318190
Name:MADDOX, SARAH KATHRYN
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:KATHRYN
Last Name:MADDOX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10580 SW MCDONALD ST
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-4867
Mailing Address - Country:US
Mailing Address - Phone:971-599-1335
Mailing Address - Fax:
Practice Address - Street 1:10580 SW MCDONALD ST
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-4867
Practice Address - Country:US
Practice Address - Phone:971-599-1335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR9141101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health