Provider Demographics
NPI:1649404377
Name:MAKSIMOVICH, MICHAEL J (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:MAKSIMOVICH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6314 RUCKER ROAD SUITE A
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220
Mailing Address - Country:US
Mailing Address - Phone:317-250-4149
Mailing Address - Fax:
Practice Address - Street 1:6314 RUCKER ROAD SUITE A
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220
Practice Address - Country:US
Practice Address - Phone:317-250-4149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-09
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005717A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1033890157OtherTYPE II NPI
INP01127780Medicare PIN