1528211620 NPI number — MILDRED GORDON MAXWELL PHD, LPC, NCC

Table of content: MILDRED GORDON MAXWELL PHD, LPC, NCC (NPI 1528211620)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528211620 NPI number — MILDRED GORDON MAXWELL PHD, LPC, NCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAXWELL
Provider First Name:
MILDRED
Provider Middle Name:
GORDON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD, LPC, NCC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MAXWELL
Provider Other First Name:
MILLIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHD, LPC, NCC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1528211620
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/18/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1027 VANCE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27608-2259
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-828-1858
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1407 HILLSBOROUGH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27605-1828
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-624-1150
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/03/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  5186 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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