Provider Demographics
NPI:1780411959
Name:PERCHUK, MAXINE (LMFT)
Entity type:Individual
Prefix:
First Name:MAXINE
Middle Name:
Last Name:PERCHUK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1141
Mailing Address - Street 2:
Mailing Address - City:LILY DALE
Mailing Address - State:NY
Mailing Address - Zip Code:14752-1141
Mailing Address - Country:US
Mailing Address - Phone:347-712-7362
Mailing Address - Fax:
Practice Address - Street 1:20 FOURTH ST # 1141
Practice Address - Street 2:
Practice Address - City:LILY DALE
Practice Address - State:NY
Practice Address - Zip Code:14752-9704
Practice Address - Country:US
Practice Address - Phone:347-613-4567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-19
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001365106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist