Healthcare Provider Details

I. General information

NPI: 1053410191
Provider Name (Legal Business Name): IRMA I PHILLIPS-MAXWELL CAP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2002 NW 13TH ST SUITE 120
GAINESVILLE FL
32609-5414
US

IV. Provider business mailing address

PO BOX 1145
GAINESVILLE FL
32602-1145
US

V. Phone/Fax

Practice location:
  • Phone: 352-376-1611
  • Fax: 352-376-9482
Mailing address:
  • Phone: 352-376-1611
  • Fax: 352-376-9482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCERTIFICATION #1979
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: