Healthcare Provider Details

I. General information

NPI: 1629584941
Provider Name (Legal Business Name): ANGELA MAYNARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2017
Last Update Date: 12/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 OAK RIDGE CT
PRESTONSBURG KY
41653-8607
US

IV. Provider business mailing address

PO BOX 390
HUNTINGTON WV
25708-0390
US

V. Phone/Fax

Practice location:
  • Phone: 606-889-1602
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: