Provider Demographics
NPI:1235634908
Name:MAXWELL, ANNETTE LYNN (LLPC)
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:LYNN
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4079 JANICE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-3771
Mailing Address - Country:US
Mailing Address - Phone:810-333-3429
Mailing Address - Fax:
Practice Address - Street 1:805 SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3771
Practice Address - Country:US
Practice Address - Phone:810-966-1972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013836101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional