=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205405859
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARISSA LYNNAE MAXHAM PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2021
-----------------------------------------------------
Last Update Date | 06/18/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 701 SHADWELL AVE
-----------------------------------------------------
City | FLORA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62839-2310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-662-8361
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 702 SHADWELL AVE
-----------------------------------------------------
City | FLORA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62839-2309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-842-4138
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2081H0002X
-----------------------------------------------------
Taxonomy Name | Hospice and Palliative Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number | 160.008997
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2081P2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number | 160008997
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------