Provider Demographics
NPI:1245694967
Name:MAXFIELD, NATHANIEL DOLE (PHD)
Entity type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:DOLE
Last Name:MAXFIELD
Suffix:
Gender:M
Credentials:PHD
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 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:813-821-8038
Mailing Address - Fax:813-974-0483
Practice Address - Street 1:4202 E FOWLER AVE
Practice Address - Street 2:PCD1017
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33620-8000
Practice Address - Country:US
Practice Address - Phone:813-974-6190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-08
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA10997235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY911WOtherBLUE CROSS BLUE SHIELD
FL022773300Medicaid