Provider Demographics
NPI:1881460194
Name:PARKS, MAXIMUS GORDON
Entity type:Individual
Prefix:
First Name:MAXIMUS
Middle Name:GORDON
Last Name:PARKS
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 1:115 HEATHER DR
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29301-5465
Mailing Address - Country:US
Mailing Address - Phone:843-494-4629
Mailing Address - Fax:
Practice Address - Street 1:10 ARBORLAND WAY
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-2201
Practice Address - Country:US
Practice Address - Phone:864-520-1614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-28
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCRBT-23-306010106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician