Provider Demographics
NPI:1659150019
Name:MAYNARD, TAYLOR ANICE
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:ANICE
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2309 E 17TH ST UNIT 204
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-8455
Mailing Address - Country:US
Mailing Address - Phone:562-485-1591
Mailing Address - Fax:
Practice Address - Street 1:2309 E 17TH ST UNIT 204
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-8455
Practice Address - Country:US
Practice Address - Phone:562-485-1591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician