=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306595376
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAX-WELL THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2022
-----------------------------------------------------
Last Update Date | 03/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6114 RICKWOOD DR NW
-----------------------------------------------------
City | HUNTSVILLE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35810-2576
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-896-5363
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9889 SW 54TH AVE
-----------------------------------------------------
City | OCALA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34476-8694
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-679-2271
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | LILLY NELSON MAXWELL
-----------------------------------------------------
Credential | LICSW, MSW, BHSC
-----------------------------------------------------
Telephone | 601-896-5363
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------