Provider Demographics
NPI:1679754857
Name:MAXWELL, TRACY JAMESON
Entity type:Individual
Prefix:MS
First Name:TRACY
Middle Name:JAMESON
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4083 CAMELLIA AVE
Mailing Address - Street 2:
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-3007
Mailing Address - Country:US
Mailing Address - Phone:310-488-2214
Mailing Address - Fax:
Practice Address - Street 1:4083 CAMELLIA AVE
Practice Address - Street 2:
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91604-3007
Practice Address - Country:US
Practice Address - Phone:310-488-2214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist