Basic Information
| Provider Information | |||||||||
| NPI: | 1720244783 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAXWELL | ||||||||
| FirstName: | CHRISTINA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PSYD, HSPP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2049 N MERIDIAN ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462021305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179247010 | ||||||||
| FaxNumber: | 3179412208 | ||||||||
| Practice Location | |||||||||
| Address1: | 927 N PENNSYLVANIA ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462041020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9274620431 | ||||||||
| FaxNumber: | 3176865810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2008 | ||||||||
| LastUpdateDate: | 10/23/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103TC0700X | 20043040A | IN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 20043040A | 01 | IN | PSYD LICENSE | OTHER |