MEDICARE: STEFANIE MAXWELL PSY. D.

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	103TC0700X	Clinical Psychologist	071-006622	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	071-006622	OTHER	IL	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1245390947
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEFANIE MAXWELL PSY. D.

Provider Business Mailing Address
First Line	:	4305 N LINCOLN AVE
Second Line	:	OFFICE J
City	:	CHICAGO
State	:	IL
Zip	:	60618-1711
Country	:	US
Telephone Number	:	773-316-1488
Fax Number	:

Provider Business Practice Location Address
First Line	:	4305 N LINCOLN AVE
Second Line	:	OFFICE J
City	:	CHICAGO
State	:	IL
Zip	:	60618-1711
Country	:	US
Telephone Number	:	773-316-1488
Fax Number	:

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

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	07/15/2011

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