Provider Demographics
NPI:1316632128
Name:MAXON, CARMEN
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:MAXON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 CATALINA DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-3915
Mailing Address - Country:US
Mailing Address - Phone:254-339-4336
Mailing Address - Fax:
Practice Address - Street 1:15140 BADGER RANCH BLVD
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-7671
Practice Address - Country:US
Practice Address - Phone:254-545-2864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-07
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
22-237023106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician