Healthcare Provider Details

I. General information

NPI: 1164903530
Provider Name (Legal Business Name): MAXWELL MARIS PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2018
Last Update Date: 05/12/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5830 OBERLIN DR STE 204
SAN DIEGO CA
92121-3754
US

IV. Provider business mailing address

5830 OBERLIN DR STE 204
SAN DIEGO CA
92121-3754
US

V. Phone/Fax

Practice location:
  • Phone: 858-609-1549
  • Fax:
Mailing address:
  • Phone: 858-609-1549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number35242
License Number StateCA
# 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: