Provider Demographics
NPI:1972086031
Name:MAYNARD, STACI BETH (PROVISIONAL TVI)
Entity type:Individual
Prefix:MS
First Name:STACI
Middle Name:BETH
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:PROVISIONAL TVI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1906 GOLDSMITH LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40218-2066
Mailing Address - Country:US
Mailing Address - Phone:502-636-3207
Mailing Address - Fax:502-636-0024
Practice Address - Street 1:1906 GOLDSMITH LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-2066
Practice Address - Country:US
Practice Address - Phone:502-636-3207
Practice Address - Fax:502-636-0024
Is Sole Proprietor?:No
Enumeration Date:2018-09-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist