Basic Information
| Provider Information | |||||||||
| NPI: | 1801463971 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAXIM HEALTHCARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2141 PALOMAR AIRPORT RD STE 350 | ||||||||
| Address2: | |||||||||
| City: | CARLSBAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920111451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604380078 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2141 PALOMAR AIRPORT RD STE 350 | ||||||||
| Address2: | |||||||||
| City: | CARLSBAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920111451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604380078 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2021 | ||||||||
| LastUpdateDate: | 06/08/2021 | ||||||||
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| AuthorizedOfficialLastName: | THIEL | ||||||||
| AuthorizedOfficialFirstName: | MADELINE | ||||||||
| AuthorizedOfficialMiddleName: | RUTH | ||||||||
| AuthorizedOfficialTitleorPosition: | BEHAVIOR THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 7602152320 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | BT | ||||||||
| NPICertificationDate: | 06/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y | 193400000X SINGLE SPECIALTY GROUP |
No ID Information.