Provider Demographics
NPI:1346706934
Name:EGHTESADI, MAXINE SHOOK
Entity Type:Individual
Prefix:MS
First Name:MAXINE
Middle Name:SHOOK
Last Name:EGHTESADI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:663 S RANCHO SANTA FE RD # 180
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-3973
Mailing Address - Country:US
Mailing Address - Phone:760-809-5198
Mailing Address - Fax:
Practice Address - Street 1:16885 VIA DEL CAMPO CT STE 314
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92127-1753
Practice Address - Country:US
Practice Address - Phone:858-987-4143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-19
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician