Basic Information
| Provider Information | |||||||||
| NPI: | 1417399098 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAXSON | ||||||||
| FirstName: | TYLER | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | M.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14780 W. MOUNTAIN VIEW BLVD. | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | SURPRISE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853747280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805937384 | ||||||||
| FaxNumber: | 8777965302 | ||||||||
| Practice Location | |||||||||
| Address1: | 14780 W. MOUNTAIN VIEW BLVD. | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | SURPRISE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853747280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6233747774 | ||||||||
| FaxNumber: | 8777965302 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2013 | ||||||||
| LastUpdateDate: | 10/07/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 103TC0700X | 4642 | AZ | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.