Provider Demographics
NPI:1417399098
Name:MAXSON, TYLER C (MA)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:C
Last Name:MAXSON
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14780 W. MOUNTAIN VIEW BLVD.
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-7280
Mailing Address - Country:US
Mailing Address - Phone:480-593-7384
Mailing Address - Fax:877-796-5302
Practice Address - Street 1:14780 W. MOUNTAIN VIEW BLVD.
Practice Address - Street 2:SUITE 110
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-7280
Practice Address - Country:US
Practice Address - Phone:623-374-7774
Practice Address - Fax:877-796-5302
Is Sole Proprietor?:No
Enumeration Date:2013-07-23
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ4642103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program