Provider Demographics
NPI:1740738814
Name:MAYNARD, RITA ELLEN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:RITA
Middle Name:ELLEN
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 B AVE
Mailing Address - Street 2:SUITE R
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-3055
Mailing Address - Country:US
Mailing Address - Phone:503-692-4092
Mailing Address - Fax:
Practice Address - Street 1:311 B AVE
Practice Address - Street 2:SUITE R
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034-3055
Practice Address - Country:US
Practice Address - Phone:503-692-4092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-16
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR847103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical