Provider Demographics
NPI:1235400045
Name:MAXSON, TERRY L (LCSW)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:L
Last Name:MAXSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5275 MARKET ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92114-2212
Mailing Address - Country:US
Mailing Address - Phone:619-857-6799
Mailing Address - Fax:
Practice Address - Street 1:5275 MARKET ST
Practice Address - Street 2:SUITE E
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92114-2212
Practice Address - Country:US
Practice Address - Phone:619-857-6799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-25
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALC 123821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical