Provider Demographics
NPI:1922292218
Name:ANTOR, MAXWELL JACKSON
Entity Type:Individual
Prefix:MR
First Name:MAXWELL
Middle Name:JACKSON
Last Name:ANTOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 32ND ST
Mailing Address - Street 2:#2
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-2978
Mailing Address - Country:US
Mailing Address - Phone:415-710-2617
Mailing Address - Fax:
Practice Address - Street 1:4175 LAKESIDE DR
Practice Address - Street 2:#110
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94806-5774
Practice Address - Country:US
Practice Address - Phone:510-262-6551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-30
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health