Provider Demographics
NPI:1942440235
Name:MAYNARD, MARLA JOY (MFT)
Entity Type:Individual
Prefix:
First Name:MARLA
Middle Name:JOY
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25634 SANTA BARBARA ST
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-5830
Mailing Address - Country:US
Mailing Address - Phone:951-902-9515
Mailing Address - Fax:951-346-3707
Practice Address - Street 1:25634 SANTA BARBARA ST
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92557-5830
Practice Address - Country:US
Practice Address - Phone:951-902-9515
Practice Address - Fax:951-346-3707
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-25
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46876106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist