Basic Information
| Provider Information | |||||||||
| NPI: | 1871544577 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAX WELL THERAPY L.L.C. | ||||||||
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| OtherOrganizationName: | MAX WELL PHYSICAL THERAPY & MASSAGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1289 S LINDEN RD STE A | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485323499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102309750 | ||||||||
| FaxNumber: | 8102308799 | ||||||||
| Practice Location | |||||||||
| Address1: | 1289 S LINDEN RD STE A | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485323499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102309750 | ||||||||
| FaxNumber: | 8102308799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 03/07/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | MAXWELL | ||||||||
| AuthorizedOfficialFirstName: | JILLAYNE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8102309750 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MAX WELL THERAPY LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | 03/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225XP0200X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225200000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 225700000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0B50901 | 01 | BCBS SP | OTHER | 1008285 | 01 | MI | MCLAREN HEALTH ADVANTAGE | OTHER | 383335 | 01 | MI | PPOM | OTHER | 4383090 | 05 | MI | MEDICAID | 0B50886 | 01 | MI | BCBS OT | OTHER | 105378600 | 01 | MI | US DEPT OF LABOR | OTHER | 0B511320 | 01 | MI | BCBS GROUP # | OTHER | 7368023 | 01 | MI | AETNA | OTHER |