Provider Demographics
NPI:1982260329
Name:DUSKY, MAXWELL ARISTAEUS (LPC)
Entity Type:Individual
Prefix:
First Name:MAXWELL
Middle Name:ARISTAEUS
Last Name:DUSKY
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2842 N MULE DEER WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-7812
Mailing Address - Country:US
Mailing Address - Phone:208-353-2591
Mailing Address - Fax:
Practice Address - Street 1:3017 S MERIDIAN RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7962
Practice Address - Country:US
Practice Address - Phone:208-888-6123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-10
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional