Provider Demographics
NPI:1215077011
Name:MAYNARD, KRISTINE (LCSW)
Entity type:Individual
Prefix:MS
First Name:KRISTINE
Middle Name:
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 S. LA GRANGE RD
Mailing Address - Street 2:STE #9
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525
Mailing Address - Country:US
Mailing Address - Phone:708-921-3639
Mailing Address - Fax:708-588-1501
Practice Address - Street 1:1030 S. LA GRANGE RD
Practice Address - Street 2:STE #9
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525
Practice Address - Country:US
Practice Address - Phone:708-921-3639
Practice Address - Fax:708-588-1501
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490082761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical