Provider Demographics
NPI:1477588929
Name:MAYNARD, EDWARD S (PHD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:S
Last Name:MAYNARD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1305 GREYLYN DR
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28104-6088
Mailing Address - Country:US
Mailing Address - Phone:704-321-5183
Mailing Address - Fax:704-321-0199
Practice Address - Street 1:5801 PINEVILLE MATTHEWS RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-3432
Practice Address - Country:US
Practice Address - Phone:704-341-5326
Practice Address - Fax:704-541-5454
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2776103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical