Provider Demographics
NPI:1669539813
Name:MAYNARD, MICHAEL CASEY (MSPT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CASEY
Last Name:MAYNARD
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 E COMMERCE WAY
Mailing Address - Street 2:UNIT 1413
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95834-9634
Mailing Address - Country:US
Mailing Address - Phone:916-285-0945
Mailing Address - Fax:
Practice Address - Street 1:4860 Y STREET SUITE 1100
Practice Address - Street 2:UCDMC PM&R THERAPIES ANCILLARY SERVICES
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817
Practice Address - Country:US
Practice Address - Phone:916-734-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT33257225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT33257OtherPHYSICAL THERAPY LICENSE