Provider Demographics
NPI:1700268182
Name:MAXWELL, CASILDA (PHD)
Entity Type:Individual
Prefix:DR
First Name:CASILDA
Middle Name:
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 68TH ST SE
Mailing Address - Street 2:CAMPUS CLINIC
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548-6927
Mailing Address - Country:US
Mailing Address - Phone:616-258-7429
Mailing Address - Fax:616-493-6034
Practice Address - Street 1:300 68TH ST SE
Practice Address - Street 2:CAMPUS CLINIC
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49548-6927
Practice Address - Country:US
Practice Address - Phone:616-258-7429
Practice Address - Fax:616-493-6034
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-23
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301017793103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical