Provider Demographics
NPI:1629388038
Name:MAYNOR, AUDREY RAE (MED, LPC)
Entity Type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:RAE
Last Name:MAYNOR
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1029 HENRY DR
Mailing Address - Street 2:
Mailing Address - City:ALABASTER
Mailing Address - State:AL
Mailing Address - Zip Code:35007-8947
Mailing Address - Country:US
Mailing Address - Phone:205-240-2372
Mailing Address - Fax:
Practice Address - Street 1:150 GLENWOOD LN
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35242-5700
Practice Address - Country:US
Practice Address - Phone:205-795-3214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-19
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2238323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility