Provider Demographics
NPI:1407102718
Name:MAYNARD, ROXANNE (LPC, LCDC)
Entity Type:Individual
Prefix:
First Name:ROXANNE
Middle Name:
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:LPC, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4203 GARDENDALE ST STE C214
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3174
Mailing Address - Country:US
Mailing Address - Phone:210-243-0693
Mailing Address - Fax:877-287-0053
Practice Address - Street 1:4203 GARDENDALE ST STE C214
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229
Practice Address - Country:US
Practice Address - Phone:210-243-0693
Practice Address - Fax:877-287-0053
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-24
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX73188101YM0800X, 101YP2500X
OK5444101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX351033101Medicaid