Healthcare Provider Details

I. General information

NPI: 1063104677
Provider Name (Legal Business Name): MAXINE DEFANK LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2023
Last Update Date: 07/03/2026
Certification Date: 07/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 LOMAS SANTA FE DR STE 490
SOLANA BEACH CA
92075-1287
US

IV. Provider business mailing address

201 LOMAS SANTA FE DR STE 490
SOLANA BEACH CA
92075-1287
US

V. Phone/Fax

Practice location:
  • Phone: 850-564-6130
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPCC22480
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: