Provider Demographics
NPI:1275036808
Name:MAYNARD, MARY (ATC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 EAST ST STE C
Mailing Address - Street 2:
Mailing Address - City:PLAINVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06062-2935
Mailing Address - Country:US
Mailing Address - Phone:860-793-6882
Mailing Address - Fax:
Practice Address - Street 1:240 EAST ST STE C
Practice Address - Street 2:
Practice Address - City:PLAINVILLE
Practice Address - State:CT
Practice Address - Zip Code:06062-2935
Practice Address - Country:US
Practice Address - Phone:860-793-6882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-09
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT9322255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer