Provider Demographics
NPI:1215599485
Name:MAXWELL, GREGORY GLEN (LMFT)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:GLEN
Last Name:MAXWELL
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5412
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93539-5412
Mailing Address - Country:US
Mailing Address - Phone:661-478-8884
Mailing Address - Fax:
Practice Address - Street 1:320 E PALMDALE BLVD
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-4598
Practice Address - Country:US
Practice Address - Phone:661-729-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA128748106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist