Provider Demographics
NPI:1043702442
Name:MAXSON, RANDY R
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:R
Last Name:MAXSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 ROAD 5507
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NM
Mailing Address - Zip Code:87413-9313
Mailing Address - Country:US
Mailing Address - Phone:707-900-8073
Mailing Address - Fax:707-812-6124
Practice Address - Street 1:23 ROAD 5507
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NM
Practice Address - Zip Code:87413-9313
Practice Address - Country:US
Practice Address - Phone:707-900-8073
Practice Address - Fax:707-812-6124
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician