Provider Demographics
NPI:1699310110
Name:MAXWELL, MALLORIE ANN
Entity type:Individual
Prefix:
First Name:MALLORIE
Middle Name:ANN
Last Name:MAXWELL
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 1:3400 GOLDING RD
Mailing Address - Street 2:
Mailing Address - City:BROWNWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76801-7667
Mailing Address - Country:US
Mailing Address - Phone:325-642-4936
Mailing Address - Fax:
Practice Address - Street 1:3400 GOLDING RD
Practice Address - Street 2:
Practice Address - City:BROWNWOOD
Practice Address - State:TX
Practice Address - Zip Code:76801-7667
Practice Address - Country:US
Practice Address - Phone:325-642-4936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-07
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX120170225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist