Basic Information
| Provider Information | |||||||||
| NPI: | 1104550482 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHRAVORAXAY | ||||||||
| FirstName: | MAISY | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10970 | ||||||||
| Address2: | |||||||||
| City: | SAINT PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337330970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273277656 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2188 58TH ST N | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337603112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273277656 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2022 | ||||||||
| LastUpdateDate: | 08/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 29219 | MN | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.