Provider Demographics
NPI:1912284860
Name:MAXWELL, LATIA MONIQUE (LCSW)
Entity Type:Individual
Prefix:
First Name:LATIA
Middle Name:MONIQUE
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3511 N 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-4010
Mailing Address - Country:US
Mailing Address - Phone:850-525-4545
Mailing Address - Fax:
Practice Address - Street 1:1201 W LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-1857
Practice Address - Country:US
Practice Address - Phone:850-469-3826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-07
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW100031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical