Provider Demographics
NPI:1639687957
Name:CERNY, MAXWELL TAYLOR
Entity Type:Individual
Prefix:
First Name:MAXWELL
Middle Name:TAYLOR
Last Name:CERNY
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 1:1120 9TH AVE S APT 103
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-5566
Mailing Address - Country:US
Mailing Address - Phone:608-769-5252
Mailing Address - Fax:
Practice Address - Street 1:1120 9TH AVE S APT 103
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-5566
Practice Address - Country:US
Practice Address - Phone:608-769-5252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN30702255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer