Provider Demographics
NPI:1275995417
Name:MAXWELL, ELIJAH (LMP)
Entity Type:Individual
Prefix:
First Name:ELIJAH
Middle Name:
Last Name:MAXWELL
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3110 LAUREL LN
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-1522
Mailing Address - Country:US
Mailing Address - Phone:360-819-9728
Mailing Address - Fax:
Practice Address - Street 1:1639 KRESKY AVE
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-8912
Practice Address - Country:US
Practice Address - Phone:360-807-4711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-27
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60590359225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist