Provider Demographics
NPI:1184192916
Name:MAYNARD, MICHELE BURNS (PTA)
Entity Type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:BURNS
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 WOODVALE LN
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29801-7291
Mailing Address - Country:US
Mailing Address - Phone:803-292-9156
Mailing Address - Fax:
Practice Address - Street 1:80 PHYSICIAN DR
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-6388
Practice Address - Country:US
Practice Address - Phone:803-292-9156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-09
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1861225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant