Provider Demographics
NPI:1568914711
Name:SEARS, MAXWELL
Entity Type:Individual
Prefix:
First Name:MAXWELL
Middle Name:
Last Name:SEARS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MAXWELL
Other - Middle Name:
Other - Last Name:SEARS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:420 FAIRCOTH COURT
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252
Mailing Address - Country:US
Mailing Address - Phone:404-324-9159
Mailing Address - Fax:
Practice Address - Street 1:420 FAIRCLOTH CT
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30252-4050
Practice Address - Country:US
Practice Address - Phone:404-324-9159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-03
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC009199101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA90-0979643Medicaid