Provider Demographics
NPI:1760862569
Name:MAYNARD, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MAYNARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 VILLARD ST
Mailing Address - Street 2:
Mailing Address - City:CHENEY
Mailing Address - State:WA
Mailing Address - Zip Code:99004-1253
Mailing Address - Country:US
Mailing Address - Phone:503-298-0413
Mailing Address - Fax:
Practice Address - Street 1:1801 E UPRIVER DR
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99207-5181
Practice Address - Country:US
Practice Address - Phone:503-298-0413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-05
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT60571474225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist