Healthcare Provider Details

I. General information

NPI: 1114379468
Provider Name (Legal Business Name): CHRIS MAXWELL LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2016
Last Update Date: 07/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10637 MCMICHAEL LN SW
ALBUQUERQUE NM
87121-3689
US

IV. Provider business mailing address

10637 MCMICHAEL LN SW
ALBUQUERQUE NM
87121-3689
US

V. Phone/Fax

Practice location:
  • Phone: 505-232-0634
  • Fax:
Mailing address:
  • Phone: 505-232-0634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0162921
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: