Provider Demographics
NPI:1134467061
Name:MAXWELL, BRIAN L (CACII, NCACI)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:L
Last Name:MAXWELL
Suffix:
Gender:M
Credentials:CACII, NCACI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 DANIEL MORRALL LN
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29440-6888
Mailing Address - Country:US
Mailing Address - Phone:843-344-2975
Mailing Address - Fax:
Practice Address - Street 1:23 DANIEL MORRALL LN
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-6888
Practice Address - Country:US
Practice Address - Phone:843-344-2975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-28
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1301178101YA0400X
SC013885101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC013885OtherNCACI
SC1301178OtherCACII