Provider Demographics
NPI:1952898280
Name:MAXIE, JAMES JR (MA,QMHP-CS)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:
Last Name:MAXIE
Suffix:JR
Gender:M
Credentials:MA,QMHP-CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1840 LOGAN ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-2316
Mailing Address - Country:US
Mailing Address - Phone:318-573-3942
Mailing Address - Fax:
Practice Address - Street 1:200 N THOMAS DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-6503
Practice Address - Country:US
Practice Address - Phone:318-573-3942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA101YA0400X, 101YM0800X, 385HR2055X, 171M00000X
101YM0800X, 175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No175T00000XOther Service ProvidersPeer Specialist
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0000000Medicaid
LA11023Medicaid