Provider Demographics
NPI:1215147053
Name:MAXWELL, TERESA MYERS (LCSW)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:MYERS
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 ECLIPSE LOOP
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:FL
Mailing Address - Zip Code:32439-2697
Mailing Address - Country:US
Mailing Address - Phone:901-456-2479
Mailing Address - Fax:
Practice Address - Street 1:111 ECLIPSE LOOP
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:FL
Practice Address - Zip Code:32439-2697
Practice Address - Country:US
Practice Address - Phone:901-456-2479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW00000043761041C0700X
MSC104901041C0700X
FLSW130311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3926624Medicare ID - Type Unspecified