Provider Demographics
NPI:1487324877
Name:MATTOX, ROBERT JAMES (EDD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JAMES
Last Name:MATTOX
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:BOB
Other - Middle Name:
Other - Last Name:MATTOX
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:EDD
Mailing Address - Street 1:82 WILLIAM WAY
Mailing Address - Street 2:
Mailing Address - City:ELLIJAY
Mailing Address - State:GA
Mailing Address - Zip Code:30540-7231
Mailing Address - Country:US
Mailing Address - Phone:770-990-9197
Mailing Address - Fax:
Practice Address - Street 1:82 WILLIAM WAY
Practice Address - Street 2:
Practice Address - City:ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30540-7231
Practice Address - Country:US
Practice Address - Phone:770-990-9197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1489101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1489OtherLICENSED PROFESSIONAL COUNSELOR GA