Provider Demographics
NPI:1962069864
Name:MAYNARD, ALLYSON CAROL (PT, DPT)
Entity type:Individual
Prefix:
First Name:ALLYSON
Middle Name:CAROL
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5430 SOUTHRIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-5520
Mailing Address - Country:US
Mailing Address - Phone:949-351-2635
Mailing Address - Fax:
Practice Address - Street 1:155 RADIO DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2619
Practice Address - Country:US
Practice Address - Phone:952-831-8742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-26
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47302081S0010X
MN11489225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine