Basic Information
| Provider Information | |||||||||
| NPI: | 1326443698 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | MAXWELL | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11 RIVERWOOD DR | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020481775 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 103 COMMERCIAL STREET | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085804691 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2014 | ||||||||
| LastUpdateDate: | 10/29/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.