Provider Demographics
NPI:1538374558
Name:MATTOX, BENNIE CECILIA
Entity type:Individual
Prefix:
First Name:BENNIE
Middle Name:CECILIA
Last Name:MATTOX
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:PO BOX 1988
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31702-1988
Mailing Address - Country:US
Mailing Address - Phone:229-430-4005
Mailing Address - Fax:229-430-4047
Practice Address - Street 1:1120 W BROAD AVE
Practice Address - Street 2:SUITE C-4
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-4397
Practice Address - Country:US
Practice Address - Phone:229-430-4005
Practice Address - Fax:229-430-4047
Is Sole Proprietor?:No
Enumeration Date:2007-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW0031481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical