Provider Demographics
NPI:1659469831
Name:MAYNARD, A GALE (LICSW)
Entity Type:Individual
Prefix:MS
First Name:A
Middle Name:GALE
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:389 MAIN ST
Mailing Address - Street 2:STE 303
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-5017
Mailing Address - Country:US
Mailing Address - Phone:781-324-2381
Mailing Address - Fax:781-388-1817
Practice Address - Street 1:389 MAIN ST
Practice Address - Street 2:STE 303
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-5017
Practice Address - Country:US
Practice Address - Phone:781-324-2381
Practice Address - Fax:781-388-1817
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10216971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P23610Medicare UPIN