Provider Demographics
NPI:1104550482
Name:PHRAVORAXAY, MAISY LEE (MSW)
Entity type:Individual
Prefix:
First Name:MAISY
Middle Name:LEE
Last Name:PHRAVORAXAY
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10970
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33733-0970
Mailing Address - Country:US
Mailing Address - Phone:727-327-7656
Mailing Address - Fax:
Practice Address - Street 1:2188 58TH ST N
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33760-3112
Practice Address - Country:US
Practice Address - Phone:727-327-7656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-13
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN29219101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty