Provider Demographics
NPI:1831223312
Name:MAYNARD, TERI L
Entity type:Individual
Prefix:DR
First Name:TERI
Middle Name:L
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 DIXIE HWY
Mailing Address - Street 2:SUITE 130
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40258-3913
Mailing Address - Country:US
Mailing Address - Phone:502-582-7484
Mailing Address - Fax:502-582-7646
Practice Address - Street 1:220 ABRAHAM FLEXNER WAY
Practice Address - Street 2:6TH FLOOR-PSYCHOLOGY DEPARTMENT
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3826
Practice Address - Country:US
Practice Address - Phone:502-582-7484
Practice Address - Fax:502-582-7646
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1509103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30615058Medicaid
KY7100230110 (JPG)Medicaid
KYK067550 (JPG)Medicare PIN