Provider Demographics
NPI:1881103364
Name:MAYNARD, TERRY
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:MAYNARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27801 EUCLID AVE STE 610
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44132-3575
Mailing Address - Country:US
Mailing Address - Phone:216-731-1967
Mailing Address - Fax:216-289-1978
Practice Address - Street 1:27801 EUCLID AVE STE 610
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44132-3575
Practice Address - Country:US
Practice Address - Phone:216-731-1967
Practice Address - Fax:216-289-1978
Is Sole Proprietor?:No
Enumeration Date:2017-09-27
Last Update Date:2022-07-21
Deactivation Date:2017-10-03
Deactivation Code:
Reactivation Date:2022-06-22
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.120822101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)