Provider Demographics
NPI:1063572808
Name:MADDUX, RENEE R (PT)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:R
Last Name:MADDUX
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4005 CANTON RD
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-2739
Mailing Address - Country:US
Mailing Address - Phone:770-728-8833
Mailing Address - Fax:678-668-7469
Practice Address - Street 1:4005 CANTON RD
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-2739
Practice Address - Country:US
Practice Address - Phone:770-728-8833
Practice Address - Fax:678-668-7469
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6052225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA321993OtherWELLCARE
GA10040447OtherAMERIGROUP
GA6052OtherPHYSICAL THERAPY LICENSE
GA000885585AMedicaid