Provider Demographics
NPI:1811230634
Name:MAXWELL, VICTORIA (LAADC-CA)
Entity Type:Individual
Prefix:MS
First Name:VICTORIA
Middle Name:
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:LAADC-CA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2970 MARKET STREET
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102
Mailing Address - Country:US
Mailing Address - Phone:619-236-9492
Mailing Address - Fax:206-323-0933
Practice Address - Street 1:2970 MARKET STREET
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102
Practice Address - Country:US
Practice Address - Phone:619-236-9492
Practice Address - Fax:206-323-0933
Is Sole Proprietor?:No
Enumeration Date:2013-03-29
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60316188101YA0400X
CALCI2300518101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)