Healthcare Provider Details

I. General information

NPI: 1407982713
Provider Name (Legal Business Name): DEANDRE A. MAXWELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 M ST
FRESNO CA
93721-1808
US

IV. Provider business mailing address

481 N ORANGEWOOD AVE
FRESNO CA
93727-3230
US

V. Phone/Fax

Practice location:
  • Phone: 559-264-2700
  • Fax: 559-264-2767
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC051620318
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: