Provider Demographics
NPI:1972323814
Name:MAXUME, DECIDEL
Entity type:Individual
Prefix:
First Name:DECIDEL
Middle Name:
Last Name:MAXUME
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 ELM ST
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-4913
Mailing Address - Country:US
Mailing Address - Phone:347-965-1153
Mailing Address - Fax:
Practice Address - Street 1:147 ELM ST
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-4913
Practice Address - Country:US
Practice Address - Phone:347-965-1153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-15
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF406333-01163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & AdolescentGroup - Single Specialty