Provider Demographics
NPI:1265884597
Name:KING, MAXWELL (PTA)
Entity type:Individual
Prefix:MR
First Name:MAXWELL
Middle Name:
Last Name:KING
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:MR
Other - First Name:MAXWELL
Other - Middle Name:BUTLER
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:48 MOORLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02905-3513
Mailing Address - Country:US
Mailing Address - Phone:401-327-2048
Mailing Address - Fax:
Practice Address - Street 1:48 MOORLAND AVENUE
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02905
Practice Address - Country:US
Practice Address - Phone:401-327-2048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPTA01056225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant