Provider Demographics
NPI:1376682187
Name:MAYNARD, SUSAN CAROL (MSW, LICSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:CAROL
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:876 BEACON ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02459-1835
Mailing Address - Country:US
Mailing Address - Phone:617-558-9445
Mailing Address - Fax:
Practice Address - Street 1:1415 BEACON ST
Practice Address - Street 2:#301
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-4816
Practice Address - Country:US
Practice Address - Phone:617-620-1963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10170131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP07389OtherBLUE CROSS BLUE SHIELD