Provider Demographics
NPI:1669762241
Name:MAYNARD, SUSANNE LYNN (LMSW,MT-BC)
Entity type:Individual
Prefix:MS
First Name:SUSANNE
Middle Name:LYNN
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:LMSW,MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 E MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:KEENE
Mailing Address - State:TX
Mailing Address - Zip Code:76059-2351
Mailing Address - Country:US
Mailing Address - Phone:817-897-5598
Mailing Address - Fax:
Practice Address - Street 1:203 E MAPLE ST
Practice Address - Street 2:
Practice Address - City:KEENE
Practice Address - State:TX
Practice Address - Zip Code:76059-2351
Practice Address - Country:US
Practice Address - Phone:817-897-5598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-15
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX08861225A00000X
TX59606104100000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator