Provider Demographics
NPI:1306320767
Name:MAXWELL, TANGELY (COMMUNITY BASED)
Entity type:Individual
Prefix:MS
First Name:TANGELY
Middle Name:
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:COMMUNITY BASED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 MONROE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:MIDWAY
Mailing Address - State:FL
Mailing Address - Zip Code:32343-2212
Mailing Address - Country:US
Mailing Address - Phone:850-570-6551
Mailing Address - Fax:
Practice Address - Street 1:13 MONROE CREEK DR
Practice Address - Street 2:
Practice Address - City:MIDWAY
Practice Address - State:FL
Practice Address - Zip Code:32343-2212
Practice Address - Country:US
Practice Address - Phone:850-570-6551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-21
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021165900Medicaid