Provider Demographics
NPI:1225847767
Name:MAYNE, JOHNDA E (LMSW)
Entity type:Individual
Prefix:
First Name:JOHNDA
Middle Name:E
Last Name:MAYNE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:482 BLACK RIVER PKWY
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-2416
Mailing Address - Country:US
Mailing Address - Phone:315-782-1777
Mailing Address - Fax:315-785-8628
Practice Address - Street 1:611 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-1337
Practice Address - Country:US
Practice Address - Phone:315-788-1530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY125604104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker