Provider Demographics
NPI:1952317190
Name:MAYNARD, DIANNA L (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DIANNA
Middle Name:L
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 CARPENTERS CIR
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30601-3102
Mailing Address - Country:US
Mailing Address - Phone:346-324-8588
Mailing Address - Fax:
Practice Address - Street 1:170 CARPENTERS CIR
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30601-3102
Practice Address - Country:US
Practice Address - Phone:346-324-8588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2024-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6275235Z00000X
WVSLP-1043235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA870796487AMedicaid