Provider Demographics
NPI:1700592359
Name:MAYNARD, WESLEY J (MBA, MSW)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:J
Last Name:MAYNARD
Suffix:
Gender:M
Credentials:MBA, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2929 WILDWOOD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-5072
Mailing Address - Country:US
Mailing Address - Phone:208-608-8375
Mailing Address - Fax:
Practice Address - Street 1:2929 WILDWOOD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-5072
Practice Address - Country:US
Practice Address - Phone:208-608-8375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-26
Last Update Date:2023-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-38700104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker