Provider Demographics
NPI:1285979922
Name:MAYNES, LISA GAIL (LCSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:GAIL
Last Name:MAYNES
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 1:991 KOVAR RD
Mailing Address - Street 2:
Mailing Address - City:FLATONIA
Mailing Address - State:TX
Mailing Address - Zip Code:78941-5912
Mailing Address - Country:US
Mailing Address - Phone:931-249-3527
Mailing Address - Fax:
Practice Address - Street 1:7272 WURZBACH RD STE 706
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-4803
Practice Address - Country:US
Practice Address - Phone:210-615-3483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-06
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX609501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program