Provider Demographics
NPI:1386859627
Name:ELLISON, MAXLYN LAVIE (MD)
Entity Type:Individual
Prefix:
First Name:MAXLYN
Middle Name:LAVIE
Last Name:ELLISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 REXWOODS DR
Mailing Address - Street 2:STE 102
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-3370
Mailing Address - Country:US
Mailing Address - Phone:919-872-5220
Mailing Address - Fax:919-872-5770
Practice Address - Street 1:2920 HIGHWOODS BLVD
Practice Address - Street 2:SUITE 127
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-1015
Practice Address - Country:US
Practice Address - Phone:919-872-5220
Practice Address - Fax:919-872-5770
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC98-008572084P0800X
NC98008572084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Not Answered2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
F95628Medicare UPIN