Healthcare Provider Details

I. General information

NPI: 1679176515
Provider Name (Legal Business Name): AMY MARISSA MAXWELL LPC, LCPC, LCAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2020
Last Update Date: 12/23/2025
Certification Date: 12/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1086 10TH ST
BOULDER CO
80302-7261
US

IV. Provider business mailing address

1086 10TH ST
BOULDER CO
80302-7261
US

V. Phone/Fax

Practice location:
  • Phone: 720-663-1296
  • Fax:
Mailing address:
  • Phone: 720-663-1296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0017549
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number92195
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number002488-01
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCC7526
License Number StateME
# 5
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberTPMC1981
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: