Provider Demographics
NPI:1750620837
Name:MAXWELL, TAMIEKA K
Entity type:Individual
Prefix:
First Name:TAMIEKA
Middle Name:K
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 W DEVON AVE
Mailing Address - Street 2:UNIT 59180
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-6000
Mailing Address - Country:US
Mailing Address - Phone:773-450-7137
Mailing Address - Fax:
Practice Address - Street 1:3401 W DEVON AVE
Practice Address - Street 2:UNIT 59180
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-6000
Practice Address - Country:US
Practice Address - Phone:773-450-7137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-08
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILX47043Medicaid