Provider Demographics
NPI:1114215746
Name:MAYNARD, BRANDON WILLIAM (PSYD, MA)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:WILLIAM
Last Name:MAYNARD
Suffix:
Gender:M
Credentials:PSYD, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 W 29TH ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-2760
Mailing Address - Country:US
Mailing Address - Phone:307-426-4728
Mailing Address - Fax:
Practice Address - Street 1:2526 SEYMOUR AVE
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001
Practice Address - Country:US
Practice Address - Phone:307-634-9653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-18
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
WY668103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health