Healthcare Provider Details

I. General information

NPI: 1912838772
Provider Name (Legal Business Name): MICHAEL MAYNARD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10B MADISON AVENUE EXT
ALBANY NY
12203-7314
US

IV. Provider business mailing address

10B MADISON AVENUE EXT
ALBANY NY
12203-7314
US

V. Phone/Fax

Practice location:
  • Phone: 518-867-3061
  • Fax: 518-867-3066
Mailing address:
  • Phone: 518-867-3061
  • Fax: 518-867-3066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: