Provider Demographics
NPI:1053410191
Name:PHILLIPS-MAXWELL, IRMA I (CAP)
Entity type:Individual
Prefix:MRS
First Name:IRMA
Middle Name:I
Last Name:PHILLIPS-MAXWELL
Suffix:
Gender:F
Credentials:CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1145
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32602-1145
Mailing Address - Country:US
Mailing Address - Phone:352-376-1611
Mailing Address - Fax:352-376-9482
Practice Address - Street 1:2002 NW 13TH ST
Practice Address - Street 2:SUITE 120
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32609-5414
Practice Address - Country:US
Practice Address - Phone:352-376-1611
Practice Address - Fax:352-376-9482
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCERTIFICATION #1979101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)