Provider Demographics
NPI:1528211620
Name:MAXWELL, MILDRED GORDON (PHD, LPC, NCC)
Entity Type:Individual
Prefix:
First Name:MILDRED
Middle Name:GORDON
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:PHD, LPC, NCC
Other - Prefix:
Other - First Name:MILLIE
Other - Middle Name:
Other - Last Name:MAXWELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD, LPC, NCC
Mailing Address - Street 1:1027 VANCE ST
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27608-2259
Mailing Address - Country:US
Mailing Address - Phone:919-828-1858
Mailing Address - Fax:
Practice Address - Street 1:1407 HILLSBOROUGH ST
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27605-1828
Practice Address - Country:US
Practice Address - Phone:919-624-1150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-03
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5186101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional