Provider Demographics
NPI:1073712592
Name:MAXSON, ELLEN JB (CBT)
Entity type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:JB
Last Name:MAXSON
Suffix:
Gender:F
Credentials:CBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:981 E 13TH SQ
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-2109
Mailing Address - Country:US
Mailing Address - Phone:772-257-0300
Mailing Address - Fax:772-409-8600
Practice Address - Street 1:777 37TH ST STE B106
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-7301
Practice Address - Country:US
Practice Address - Phone:772-299-4325
Practice Address - Fax:772-998-7997
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-14
Last Update Date:2007-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1815247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other