Provider Demographics
NPI:1306324447
Name:MAXWELL, JANELLE (LMT, MMP, CCST)
Entity type:Individual
Prefix:
First Name:JANELLE
Middle Name:
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:LMT, MMP, CCST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:396 E WOODLAKE DR APT 83
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-1637
Mailing Address - Country:US
Mailing Address - Phone:701-340-1318
Mailing Address - Fax:
Practice Address - Street 1:720 E NEW ENGLAND DR
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-3590
Practice Address - Country:US
Practice Address - Phone:701-340-1318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9512691-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist