Provider Demographics
NPI:1205405859
Name:MAXHAM, MARISSA LYNNAE (PTA)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:LYNNAE
Last Name:MAXHAM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 SHADWELL AVE
Mailing Address - Street 2:
Mailing Address - City:FLORA
Mailing Address - State:IL
Mailing Address - Zip Code:62839-2309
Mailing Address - Country:US
Mailing Address - Phone:618-842-4138
Mailing Address - Fax:
Practice Address - Street 1:701 SHADWELL AVE
Practice Address - Street 2:
Practice Address - City:FLORA
Practice Address - State:IL
Practice Address - Zip Code:62839-2310
Practice Address - Country:US
Practice Address - Phone:618-662-8361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-18
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.0089972081H0002X
IL1600089972081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No2081H0002XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationHospice and Palliative Medicine