=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073712592
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELLEN JB MAXSON CBT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2007
-----------------------------------------------------
Last Update Date | 07/14/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 777 37TH ST STE B106
-----------------------------------------------------
City | VERO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32960-7301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-299-4325
-----------------------------------------------------
Fax | 772-998-7997
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 981 E 13TH SQ
-----------------------------------------------------
City | VERO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32960-2109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-257-0300
-----------------------------------------------------
Fax | 772-409-8600
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 247200000X
-----------------------------------------------------
Taxonomy Name | Other Technician
-----------------------------------------------------
License Number | 1815
-----------------------------------------------------
License Number State |
-----------------------------------------------------