Provider Demographics
NPI:1407875933
Name:MAXWELL, CAROL
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:MAXWELL
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:PO BOX 12225
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93406-2225
Mailing Address - Country:US
Mailing Address - Phone:805-596-0401
Mailing Address - Fax:805-545-0180
Practice Address - Street 1:1313 PACIFIC ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-3317
Practice Address - Country:US
Practice Address - Phone:805-596-0401
Practice Address - Fax:805-545-0180
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC20231106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC20231OtherMFT LICENSE NUMBER