Provider Demographics
NPI:1851954408
Name:FOSTER-MAXEY, BEVERLY (LMT)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:FOSTER-MAXEY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17462 SALEM ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-5802
Mailing Address - Country:US
Mailing Address - Phone:313-319-0694
Mailing Address - Fax:
Practice Address - Street 1:17460 SALEM ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-5802
Practice Address - Country:US
Practice Address - Phone:248-469-8480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-19
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501000137225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist