Provider Demographics
NPI:1447227517
Name:MAYNARD, ROY W (PT)
Entity Type:Individual
Prefix:MR
First Name:ROY
Middle Name:W
Last Name:MAYNARD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 S RIVER RD
Mailing Address - Street 2:
Mailing Address - City:COVENTRY
Mailing Address - State:CT
Mailing Address - Zip Code:06238-1509
Mailing Address - Country:US
Mailing Address - Phone:860-742-1258
Mailing Address - Fax:
Practice Address - Street 1:90 S PARK ST
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-3336
Practice Address - Country:US
Practice Address - Phone:860-456-6312
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003733225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist