Healthcare Provider Details

I. General information

NPI: 1215147053
Provider Name (Legal Business Name): TERESA MYERS MAXWELL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 ECLIPSE LOOP
FREEPORT FL
32439-2697
US

IV. Provider business mailing address

111 ECLIPSE LOOP
FREEPORT FL
32439-2697
US

V. Phone/Fax

Practice location:
  • Phone: 901-456-2479
  • Fax:
Mailing address:
  • Phone: 901-456-2479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLSW0000004376
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC10490
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW13031
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: