Provider Demographics
NPI:1427159227
Name:FOURQUREAN, MAXZELLA S (LCSW)
Entity type:Individual
Prefix:MRS
First Name:MAXZELLA
Middle Name:S
Last Name:FOURQUREAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 E. MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NC
Mailing Address - Zip Code:27906
Mailing Address - Country:US
Mailing Address - Phone:252-335-0803
Mailing Address - Fax:252-335-9143
Practice Address - Street 1:305 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-4425
Practice Address - Country:US
Practice Address - Phone:252-335-0803
Practice Address - Fax:252-335-9143
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0042311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6003290Medicaid
NC1376MOtherBLUE CROSS BLUE SHIELD
NC6003290Medicaid