Provider Demographics
NPI:1477890713
Name:MAXWELL, SUSAN (CAP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1903 ISLAND WALK WAY
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-4797
Mailing Address - Country:US
Mailing Address - Phone:904-277-0027
Mailing Address - Fax:407-867-6261
Practice Address - Street 1:1903 ISLAND WALK WAY
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-4797
Practice Address - Country:US
Practice Address - Phone:904-277-0027
Practice Address - Fax:407-867-6261
Is Sole Proprietor?:No
Enumeration Date:2013-01-07
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
FL5294101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor