Healthcare Provider Details

I. General information

NPI: 1154875201
Provider Name (Legal Business Name): MICHELLE MAXWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2016
Last Update Date: 08/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 GARRETSON AVE
CORONA CA
92879-2420
US

IV. Provider business mailing address

1212 GARRETSON AVE
CORONA CA
92879-2420
US

V. Phone/Fax

Practice location:
  • Phone: 562-619-6632
  • Fax:
Mailing address:
  • Phone: 562-619-6632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSPA3649
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: