Provider Demographics
NPI:1437642949
Name:MAXIE, ANDRE DAVID (LMFT)
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:DAVID
Last Name:MAXIE
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30722 LINKS CT
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-3946
Mailing Address - Country:US
Mailing Address - Phone:951-295-4699
Mailing Address - Fax:
Practice Address - Street 1:30722 LINKS CT
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-3946
Practice Address - Country:US
Practice Address - Phone:951-295-4699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-08
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105950106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty