Provider Demographics
NPI:1700579158
Name:MAXWELL, ERICA BROOKE (OTD)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:BROOKE
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 REDWOOD ST
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29440-4245
Mailing Address - Country:US
Mailing Address - Phone:803-669-4042
Mailing Address - Fax:
Practice Address - Street 1:1800 EAGLE LANDING BLVD
Practice Address - Street 2:
Practice Address - City:HANAHAN
Practice Address - State:SC
Practice Address - Zip Code:29410-8517
Practice Address - Country:US
Practice Address - Phone:843-553-0656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6600225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist