=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063876407
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAXLIFE THERAPEUTIC SOLUTIONS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2016
-----------------------------------------------------
Last Update Date | 04/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 204B PITCARIN WAY SUITE #1
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30909-5766
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-319-7250
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3915 CASCADE RD SW STE 355
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30331-8520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-867-3093
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | CAROLYN WALLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-867-3093
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------