Provider Demographics
NPI:1104194067
Name:MAYNARD, ANNA PETIT
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:PETIT
Last Name:MAYNARD
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 1:1134 10TH STREET.
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302
Mailing Address - Country:US
Mailing Address - Phone:802-318-8213
Mailing Address - Fax:
Practice Address - Street 1:1134 10TH ST.
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302
Practice Address - Country:US
Practice Address - Phone:802-318-8213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-07
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical