Provider Demographics
NPI:1679095046
Name:MITTELMAN, MAXWELL JACOB
Entity Type:Individual
Prefix:
First Name:MAXWELL
Middle Name:JACOB
Last Name:MITTELMAN
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 1:1200 1ST ST NE FL 9
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-7953
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 FIRST ST NE, 9TH FLOOR
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002
Practice Address - Country:US
Practice Address - Phone:202-442-5885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-07
Last Update Date:2017-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJYKZ3HZN31681870OtherHORIZON BLUE CROSS BLUE SHIELD OMNIA SILVER HSA