Provider Demographics
NPI:1881855062
Name:MAXWELL, EILEEN JUNE (LCSW)
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:JUNE
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 N CAYUGA ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-4333
Mailing Address - Country:US
Mailing Address - Phone:607-273-7494
Mailing Address - Fax:
Practice Address - Street 1:204 N CAYUGA ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-4333
Practice Address - Country:US
Practice Address - Phone:607-273-7494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-20
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050080101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY39703YMedicare PIN