Provider Demographics
NPI:1477074268
Name:DEFRAIN, MAX
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:
Last Name:DEFRAIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3605 VISTA WAY STE 258
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-4565
Mailing Address - Country:US
Mailing Address - Phone:760-758-1480
Mailing Address - Fax:
Practice Address - Street 1:3605 VISTA WAY STE 258
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-4565
Practice Address - Country:US
Practice Address - Phone:760-758-1480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109978106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist