Healthcare Provider Details

I. General information

NPI: 1851687578
Provider Name (Legal Business Name): MAXINE JULIA MCINTOSH RADT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2011
Last Update Date: 02/05/2023
Certification Date: 02/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 MAGNOLIA AVE
LONG BEACH CA
90806-4521
US

IV. Provider business mailing address

2101 MAGNOLIA AVE
LONG BEACH CA
90806-4521
US

V. Phone/Fax

Practice location:
  • Phone: 562-218-1868
  • Fax:
Mailing address:
  • Phone: 562-218-1868
  • Fax: 562-591-0346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number133381
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: