Provider Demographics
NPI:1174166946
Name:MAISEL, MAX EMANUEL (PHD)
Entity type:Individual
Prefix:
First Name:MAX
Middle Name:EMANUEL
Last Name:MAISEL
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:PO BOX 1625
Mailing Address - Street 2:
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91614-0625
Mailing Address - Country:US
Mailing Address - Phone:858-449-9915
Mailing Address - Fax:
Practice Address - Street 1:14011 VENTURA BLVD STE 203A
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423-5273
Practice Address - Country:US
Practice Address - Phone:213-218-3080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-23
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31101103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical