Provider Demographics
NPI:1477219160
Name:MAYNARD, ELISE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 PAGE AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2418
Mailing Address - Country:US
Mailing Address - Phone:517-990-6210
Mailing Address - Fax:
Practice Address - Street 1:2040 AURELIUS RD
Practice Address - Street 2:
Practice Address - City:HOLT
Practice Address - State:MI
Practice Address - Zip Code:48842-1367
Practice Address - Country:US
Practice Address - Phone:517-268-9040
Practice Address - Fax:517-268-9042
Is Sole Proprietor?:No
Enumeration Date:2021-11-17
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501021595225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501021595OtherSTATE LICENSE