Provider Demographics
NPI:1306234489
Name:MAXEY, CHARLES DAVID (MA)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:DAVID
Last Name:MAXEY
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:C. DAVID
Other - Middle Name:
Other - Last Name:MAXEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:6950 SW HAMPTON ST STE 207
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8234
Mailing Address - Country:US
Mailing Address - Phone:503-928-4182
Mailing Address - Fax:
Practice Address - Street 1:6950 SW HAMPTON ST STE 207
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-8234
Practice Address - Country:US
Practice Address - Phone:503-928-4182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-25
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5067103TC0700X, 103TC2200X, 103TB0200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103T00000XBehavioral Health & Social Service ProvidersPsychologist