Provider Demographics
NPI:1245390947
Name:MAXWELL, STEFANIE (PSY D)
Entity Type:Individual
Prefix:
First Name:STEFANIE
Middle Name:
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4305 N LINCOLN AVE
Mailing Address - Street 2:OFFICE J
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-1711
Mailing Address - Country:US
Mailing Address - Phone:773-316-1488
Mailing Address - Fax:
Practice Address - Street 1:4305 N LINCOLN AVE
Practice Address - Street 2:OFFICE J
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-1711
Practice Address - Country:US
Practice Address - Phone:773-316-1488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2011-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-006622103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL071-006622OtherSTATE LICENSE NUMBER