Provider Demographics
NPI:1821589649
Name:ROSS, MAXWELL
Entity type:Individual
Prefix:
First Name:MAXWELL
Middle Name:
Last Name:ROSS
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 1:512 5TH AVE APT 22
Mailing Address - Street 2:
Mailing Address - City:ASBURY PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07712-5442
Mailing Address - Country:US
Mailing Address - Phone:908-770-4660
Mailing Address - Fax:
Practice Address - Street 1:512 5TH AVE APT 22
Practice Address - Street 2:
Practice Address - City:ASBURY PARK
Practice Address - State:NJ
Practice Address - Zip Code:07712-5442
Practice Address - Country:US
Practice Address - Phone:908-770-4660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician