Provider Demographics
NPI:1215097605
Name:MAXWELL, SUSAN (MA MFT)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:MA MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10780 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025
Mailing Address - Country:US
Mailing Address - Phone:310-475-6547
Mailing Address - Fax:310-474-5209
Practice Address - Street 1:10780 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 250
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025
Practice Address - Country:US
Practice Address - Phone:310-475-6547
Practice Address - Fax:310-474-5209
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAM25676106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist