Provider Demographics
NPI:1912534843
Name:MAYNARD, BARBARA A (LMSW)
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:A
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1503 MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-1718
Mailing Address - Country:US
Mailing Address - Phone:585-690-4217
Mailing Address - Fax:
Practice Address - Street 1:1503 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-1718
Practice Address - Country:US
Practice Address - Phone:585-690-4217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-23
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103737-1101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY154888Medicaid