Provider Demographics
NPI:1609831106
Name:MCDONALD, MAXINE (LCSW-R, CASAC)
Entity Type:Individual
Prefix:
First Name:MAXINE
Middle Name:
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:LCSW-R, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2139 EVERGREEN LN
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:NY
Mailing Address - Zip Code:14519-9705
Mailing Address - Country:US
Mailing Address - Phone:585-330-8891
Mailing Address - Fax:
Practice Address - Street 1:2139 EVERGREEN LN
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:NY
Practice Address - Zip Code:14519-9705
Practice Address - Country:US
Practice Address - Phone:585-330-8891
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5134101YA0400X
NYR042699-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY110547FKOtherPREFERRED CARE
NY110547FKOtherPREFERRED CARE
NYP8392Medicare UPIN