Provider Demographics
NPI:1578223145
Name:MAXWELL, MICHELLE NIKOLE (PEER SUPPORT SP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:NIKOLE
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:PEER SUPPORT SP
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 160
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:AK
Mailing Address - Zip Code:99574-0160
Mailing Address - Country:US
Mailing Address - Phone:907-424-8300
Mailing Address - Fax:907-424-8645
Practice Address - Street 1:602 CHASE AVE.
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:AK
Practice Address - Zip Code:99574
Practice Address - Country:US
Practice Address - Phone:907-424-8300
Practice Address - Fax:907-424-8645
Is Sole Proprietor?:No
Enumeration Date:2021-12-23
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist