Provider Demographics
NPI:1790092435
Name:MITCHELL, MAXWELL LAWRENCE STEPHEN (DC)
Entity Type:Individual
Prefix:
First Name:MAXWELL
Middle Name:LAWRENCE STEPHEN
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 WASHINGTON AVE
Mailing Address - Street 2:STE 19
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-1708
Mailing Address - Country:US
Mailing Address - Phone:203-691-5581
Mailing Address - Fax:203-691-7636
Practice Address - Street 1:765 MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-3123
Practice Address - Country:US
Practice Address - Phone:860-904-5324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-01
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001850111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor