Provider Demographics
NPI:1750999223
Name:DORSEY, MAXIMILLIAN ALEXANDER
Entity type:Individual
Prefix:
First Name:MAXIMILLIAN
Middle Name:ALEXANDER
Last Name:DORSEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 FAIRWAY DRIVE
Mailing Address - Street 2:STE 101
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33441-1817
Mailing Address - Country:US
Mailing Address - Phone:888-880-9270
Mailing Address - Fax:866-500-2186
Practice Address - Street 1:11607 SOUTHFORK AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-5220
Practice Address - Country:US
Practice Address - Phone:888-880-9270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
LA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician