Provider Demographics
NPI:1194417899
Name:MAYNARD, KYLIE KATHLEEN
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:KATHLEEN
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 1:409 ILLINOIS AVE UNIT 1D
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-2966
Mailing Address - Country:US
Mailing Address - Phone:855-205-4764
Mailing Address - Fax:
Practice Address - Street 1:409 ILLINOIS AVE UNIT 1D
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2966
Practice Address - Country:US
Practice Address - Phone:855-205-4764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208000972101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health