Provider Demographics
NPI:1871126888
Name:MAXWELL, AMITY BETH HADDON (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:AMITY
Middle Name:BETH HADDON
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 CENTER ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-2669
Mailing Address - Country:US
Mailing Address - Phone:503-945-9295
Mailing Address - Fax:
Practice Address - Street 1:OREGON STATE HOSPITAL
Practice Address - Street 2:2600 CENTER ST NE
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301
Practice Address - Country:US
Practice Address - Phone:503-945-9295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-18
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL77061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical