Provider Demographics
NPI:1659015931
Name:MAXEY, GEORGIA CARROLL (MFTC)
Entity Type:Individual
Prefix:
First Name:GEORGIA
Middle Name:CARROLL
Last Name:MAXEY
Suffix:
Gender:F
Credentials:MFTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6318 RICHMOND AVE UNIT 4101
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75214-3691
Mailing Address - Country:US
Mailing Address - Phone:303-506-3589
Mailing Address - Fax:
Practice Address - Street 1:6318 RICHMOND AVE UNIT 4101
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75214-3691
Practice Address - Country:US
Practice Address - Phone:303-506-3589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-23
Last Update Date:2022-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMFTC.0014303106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist