Provider Demographics
NPI:1790389344
Name:ANDERSON, MAXWELL REED (PHD)
Entity type:Individual
Prefix:
First Name:MAXWELL
Middle Name:REED
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 MDG / RAF LAKENHEATH
Mailing Address - Street 2:UNIT 5115
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09461
Mailing Address - Country:US
Mailing Address - Phone:314-226-8603
Mailing Address - Fax:
Practice Address - Street 1:48 MDG / RAF LAKENHEATH
Practice Address - Street 2:UNIT 5115
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09461
Practice Address - Country:US
Practice Address - Phone:314-226-8603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-24
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY61166250103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical