Provider Demographics
NPI:1548430374
Name:MAYNARD, GLENN C (LPC)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:C
Last Name:MAYNARD
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 SW TAYLOR ST
Mailing Address - Street 2:SUITE 370
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2543
Mailing Address - Country:US
Mailing Address - Phone:503-295-6265
Mailing Address - Fax:503-232-1969
Practice Address - Street 1:1020 SW TAYLOR ST
Practice Address - Street 2:SUITE 370
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2543
Practice Address - Country:US
Practice Address - Phone:503-295-6265
Practice Address - Fax:503-232-1969
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-07
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC0084101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional