Provider Demographics
NPI:1942661319
Name:MAXWELL, MARYA ELISE (LCSW)
Entity Type:Individual
Prefix:
First Name:MARYA
Middle Name:ELISE
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 1:741 HIGHLAND AVE
Mailing Address - Street 2:FORSYTH COUNTY DSS GROUND FLOOR
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-4206
Mailing Address - Country:US
Mailing Address - Phone:336-703-3653
Mailing Address - Fax:
Practice Address - Street 1:741 HIGHLAND AVE
Practice Address - Street 2:FORSYTH COUNTY DSS GROUND FLOOR
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-4206
Practice Address - Country:US
Practice Address - Phone:336-703-3653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-14
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0034281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical