Basic Information
| Provider Information | |||||||||
| NPI: | 1427159227 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOURQUREAN | ||||||||
| FirstName: | MAXZELLA | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 E. MAIN ST. | ||||||||
| Address2: | |||||||||
| City: | ELIZABETH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2523350803 | ||||||||
| FaxNumber: | 2523359143 | ||||||||
| Practice Location | |||||||||
| Address1: | 305 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ELIZABETH CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 279094425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2523350803 | ||||||||
| FaxNumber: | 2523359143 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C004231 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 6003290 | 05 | NC | MEDICAID | 1376M | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER |