Healthcare Provider Details

I. General information

NPI: 1437642949
Provider Name (Legal Business Name): ANDRE DAVID MAXIE LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2018
Last Update Date: 06/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30722 LINKS CT
TEMECULA CA
92591-3946
US

IV. Provider business mailing address

30722 LINKS CT
TEMECULA CA
92591-3946
US

V. Phone/Fax

Practice location:
  • Phone: 951-295-4699
  • Fax:
Mailing address:
  • Phone: 951-295-4699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number105950
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: