Provider Demographics
NPI:1194976241
Name:MAXWELL, KATRINA L (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:L
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:734 FOXGLOVE ST
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-3317
Mailing Address - Country:US
Mailing Address - Phone:760-707-3882
Mailing Address - Fax:
Practice Address - Street 1:1070 S SANTA FE AVE
Practice Address - Street 2:SUITE 26A
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-7007
Practice Address - Country:US
Practice Address - Phone:760-277-3465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP15604235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist