Provider Demographics
NPI:1962711960
Name:MAXWELL, DAVID MICHAEL (MA)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:MICHAEL
Last Name:MAXWELL
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 1:770 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-6431
Mailing Address - Country:US
Mailing Address - Phone:248-594-3410
Mailing Address - Fax:248-594-3424
Practice Address - Street 1:770 FOREST AVE
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-6431
Practice Address - Country:US
Practice Address - Phone:248-594-3410
Practice Address - Fax:248-594-3424
Is Sole Proprietor?:No
Enumeration Date:2010-09-25
Last Update Date:2010-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005015103T00000X
MICC-0C1870539340103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool