Provider Demographics
NPI:1235427436
Name:MAIZE, EMMANUEL GEORGE (BS)
Entity Type:Individual
Prefix:MR
First Name:EMMANUEL
Middle Name:GEORGE
Last Name:MAIZE
Suffix:
Gender:M
Credentials:BS
Other - Prefix:MR
Other - First Name:EMMANUEL
Other - Middle Name:GEORGE
Other - Last Name:MAIZE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, COUNSELING, LPCA
Mailing Address - Street 1:225 W BRECKINRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40203-2219
Mailing Address - Country:US
Mailing Address - Phone:502-561-1051
Mailing Address - Fax:502-587-7145
Practice Address - Street 1:225 W BRECKINRIDGE ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40203-2219
Practice Address - Country:US
Practice Address - Phone:502-561-1051
Practice Address - Fax:502-587-7145
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
KY1389172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No172V00000XOther Service ProvidersCommunity Health Worker