Healthcare Provider Details

I. General information

NPI: 1689155251
Provider Name (Legal Business Name): LAQUETA MAXWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2018
Last Update Date: 08/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2631 MERRICK RD STE 302
BELLMORE NY
11710-5784
US

IV. Provider business mailing address

12911 JAMAICA AVE APT 6D
RICHMOND HILL NY
11418-2665
US

V. Phone/Fax

Practice location:
  • Phone: 516-590-7575
  • Fax:
Mailing address:
  • Phone: 516-514-4528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: