Provider Demographics
NPI:1740594530
Name:MAYNARD, KAYE ELLEN (LISW)
Entity Type:Individual
Prefix:
First Name:KAYE
Middle Name:ELLEN
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 292
Mailing Address - Street 2:
Mailing Address - City:PATASKALA
Mailing Address - State:OH
Mailing Address - Zip Code:43062-0292
Mailing Address - Country:US
Mailing Address - Phone:740-963-2976
Mailing Address - Fax:740-927-0461
Practice Address - Street 1:7257 E BROAD ST SW
Practice Address - Street 2:UNIT C
Practice Address - City:PATASKALA
Practice Address - State:OH
Practice Address - Zip Code:43062-8501
Practice Address - Country:US
Practice Address - Phone:740-963-2976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-04
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.10000631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical