MEDICARE: HALIE DOMINGUE MAXWELL LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	63398	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	26734161	OTHER	TX	DRIVER'S LICENSE

General Provider Information

NPI Number	:	1033839576
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HALIE DOMINGUE MAXWELL LCSW

Provider Business Mailing Address
First Line	:	1348 HEIGHTS BLVD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77008-4209
Country	:	US
Telephone Number	:	512-751-3791
Fax Number	:

Provider Business Practice Location Address
First Line	:	1348 HEIGHTS BLVD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77008-4209
Country	:	US
Telephone Number	:	512-751-3791
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/02/2022
Last Update Date	:	09/02/2022

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