Healthcare Provider Details

I. General information

NPI: 1164138178
Provider Name (Legal Business Name): MAXIM HEALTHCARE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2023
Last Update Date: 01/24/2023
Certification Date: 01/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

293 INDEPENDENCE BLVD STE 400
VIRGINIA BEACH VA
23462-5461
US

IV. Provider business mailing address

293 INDEPENDENCE BLVD STE 400
VIRGINIA BEACH VA
23462-5461
US

V. Phone/Fax

Practice location:
  • Phone: 757-785-3338
  • Fax:
Mailing address:
  • Phone: 757-785-3338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: BRENDAN MATTHIAS WAGNER
Title or Position: REGISTERED BEHAVIOR TECHNICIAN
Credential: RBT
Phone: 571-420-1409