MEDICARE: MR. MAXWELL JACKSON ANTOR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1922292218
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MAXWELL JACKSON ANTOR

Provider Business Mailing Address
First Line	:	2411 SANTA CLARA AVE STE 25
Second Line	:
City	:	ALAMEDA
State	:	CA
Zip	:	94501-4543
Country	:	US
Telephone Number	:	510-575-9374
Fax Number	:

Provider Business Practice Location Address
First Line	:	2411 SANTA CLARA AVE STE 25
Second Line	:
City	:	ALAMEDA
State	:	CA
Zip	:	94501-4543
Country	:	US
Telephone Number	:	510-575-9374
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2007
Last Update Date	:	09/20/2024

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