Provider Demographics
NPI:1558084327
Name:MAXWELL, ADAM RYAN
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:RYAN
Last Name:MAXWELL
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:PO BOX 1847
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-8140
Mailing Address - Country:US
Mailing Address - Phone:360-423-0203
Mailing Address - Fax:360-577-0187
Practice Address - Street 1:305 S PACIFIC AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:KELSO
Practice Address - State:WA
Practice Address - Zip Code:98626
Practice Address - Country:US
Practice Address - Phone:360-423-0203
Practice Address - Fax:360-423-5068
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA390200000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101Y00000XBehavioral Health & Social Service ProvidersCounselor