Healthcare Provider Details

I. General information

NPI: 1578658167
Provider Name (Legal Business Name): SALLY D MAXWELL LP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 09/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 EAST 2ND STREET
DULUTH MN
55805
US

IV. Provider business mailing address

502 EAST 2ND STREET
DULUTH MN
55805
US

V. Phone/Fax

Practice location:
  • Phone: 218-727-8762
  • Fax:
Mailing address:
  • Phone: 218-727-8762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3150
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: