Provider Demographics
NPI:1679787774
Name:MAXWELL, SUSAN L (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:L
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3930 E CAMELBACK RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-2617
Mailing Address - Country:US
Mailing Address - Phone:602-956-5501
Mailing Address - Fax:602-468-2794
Practice Address - Street 1:3930 E CAMELBACK RD
Practice Address - Street 2:SUITE 205
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-2617
Practice Address - Country:US
Practice Address - Phone:602-956-5501
Practice Address - Fax:602-468-2794
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0276103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0132890OtherBCBS
AZZPHD276Medicare PIN