Healthcare Provider Details

I. General information

NPI: 1417399098
Provider Name (Legal Business Name): TYLER C MAXSON M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2013
Last Update Date: 10/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14780 W. MOUNTAIN VIEW BLVD. SUITE 110
SURPRISE AZ
85374-7280
US

IV. Provider business mailing address

14780 W. MOUNTAIN VIEW BLVD. SUITE 110
SURPRISE AZ
85374-7280
US

V. Phone/Fax

Practice location:
  • Phone: 623-374-7774
  • Fax: 877-796-5302
Mailing address:
  • Phone: 480-593-7384
  • Fax: 877-796-5302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4642
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: