Provider Demographics
NPI:1821293887
Name:MAXEY, DORTHY JEAN
Entity Type:Individual
Prefix:
First Name:DORTHY
Middle Name:JEAN
Last Name:MAXEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27907 S BIG HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:PARK HILL
Mailing Address - State:OK
Mailing Address - Zip Code:74451
Mailing Address - Country:US
Mailing Address - Phone:918-457-4801
Mailing Address - Fax:918-457-4801
Practice Address - Street 1:27907 S BIG HOLLOW RD
Practice Address - Street 2:
Practice Address - City:PARK HILL
Practice Address - State:OK
Practice Address - Zip Code:74451
Practice Address - Country:US
Practice Address - Phone:918-457-4801
Practice Address - Fax:918-457-4801
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK320600000X, 347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Not Answered347C00000XTransportation ServicesPrivate Vehicle