Provider Demographics
NPI:1891112397
Name:SPAIN, MAXINE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MAXINE
Middle Name:
Last Name:SPAIN
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 NW INTERSTATE 410 LOOP FRONTAGE RD #690
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-1005
Mailing Address - Country:US
Mailing Address - Phone:210-457-2000
Mailing Address - Fax:
Practice Address - Street 1:45 NW INTERSTATE 410 LOOP FRONTAGE RD
Practice Address - Street 2:#690
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-1005
Practice Address - Country:US
Practice Address - Phone:210-457-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-21
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109044235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist