Provider Demographics
NPI:1346776804
Name:ISOM, MAXILEA
Entity Type:Individual
Prefix:
First Name:MAXILEA
Middle Name:
Last Name:ISOM
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 1:2079 EGLIN AVE APT A
Mailing Address - Street 2:
Mailing Address - City:HOLLOMAN AFB
Mailing Address - State:NM
Mailing Address - Zip Code:88330-7209
Mailing Address - Country:US
Mailing Address - Phone:347-485-8386
Mailing Address - Fax:
Practice Address - Street 1:2079 EGLIN AVE APT A
Practice Address - Street 2:
Practice Address - City:HOLLOMAN, AFB
Practice Address - State:NM
Practice Address - Zip Code:88330
Practice Address - Country:US
Practice Address - Phone:347-485-8386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-03
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician