Provider Demographics
NPI:1154644680
Name:MAXWELL, ANGELA M (LCSW)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:M
Other - Last Name:BURNETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7431 114TH AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33773-5119
Mailing Address - Country:US
Mailing Address - Phone:800-632-6074
Mailing Address - Fax:
Practice Address - Street 1:6110 SHALLOWFORD RD
Practice Address - Street 2:C/O CRC
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-1894
Practice Address - Country:US
Practice Address - Phone:800-632-6074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-11
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW00000050821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I806255Medicare PIN