Provider Demographics
NPI:1124477393
Name:MAYNARD, STEPHEN (LCSW)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:
Last Name:MAYNARD
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 N EMERSON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-3821
Mailing Address - Country:US
Mailing Address - Phone:360-261-7020
Mailing Address - Fax:
Practice Address - Street 1:1710 ALLEN ST
Practice Address - Street 2:
Practice Address - City:KELSO
Practice Address - State:WA
Practice Address - Zip Code:98626-4907
Practice Address - Country:US
Practice Address - Phone:360-261-7020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-08
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL58231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical