Healthcare Provider Details

I. General information

NPI: 1104550482
Provider Name (Legal Business Name): MAISY LEE PHRAVORAXAY MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2022
Last Update Date: 08/01/2022
Certification Date: 08/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2188 58TH ST N
CLEARWATER FL
33760-3112
US

IV. Provider business mailing address

PO BOX 10970
SAINT PETERSBURG FL
33733-0970
US

V. Phone/Fax

Practice location:
  • Phone: 727-327-7656
  • Fax:
Mailing address:
  • Phone: 727-327-7656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number29219
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: