Provider Demographics
NPI:1063270627
Name:KNIGHTEN, MAXIE LEE
Entity type:Individual
Prefix:
First Name:MAXIE
Middle Name:LEE
Last Name:KNIGHTEN
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 1:9704 S LOWE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-1013
Mailing Address - Country:US
Mailing Address - Phone:773-366-0055
Mailing Address - Fax:773-364-7200
Practice Address - Street 1:4131 S STATE ST STE F
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60609-2942
Practice Address - Country:US
Practice Address - Phone:773-366-0055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-08
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health