Provider Demographics
NPI:1275270340
Name:MAYNARD, KARISSA
Entity Type:Individual
Prefix:
First Name:KARISSA
Middle Name:
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 1:101 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-2086
Mailing Address - Country:US
Mailing Address - Phone:218-724-3122
Mailing Address - Fax:833-933-0639
Practice Address - Street 1:1522 E SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55812-1634
Practice Address - Country:US
Practice Address - Phone:218-724-3122
Practice Address - Fax:833-933-0639
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-19
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician