Provider Demographics
NPI:1215535505
Name:ENNIST, MAXWELL (LMT)
Entity Type:Individual
Prefix:MR
First Name:MAXWELL
Middle Name:
Last Name:ENNIST
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3504 ROCHAMBEAU AVE APT 1J
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-1376
Mailing Address - Country:US
Mailing Address - Phone:914-315-9088
Mailing Address - Fax:
Practice Address - Street 1:210 BEDFORD PARK BLVD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467
Practice Address - Country:US
Practice Address - Phone:914-315-9088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0308231225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty