Provider Demographics
NPI:1356824692
Name:MOSES, MAXIE
Entity Type:Individual
Prefix:
First Name:MAXIE
Middle Name:
Last Name:MOSES
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 1:1414 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-3902
Mailing Address - Country:US
Mailing Address - Phone:708-681-4357
Mailing Address - Fax:
Practice Address - Street 1:1000 S AUSTIN BLVD
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60304-2335
Practice Address - Country:US
Practice Address - Phone:312-731-3867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health