=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134609761
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMILY LYNN MAYMON PT, DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2018
-----------------------------------------------------
Last Update Date | 12/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1801 PHOENIX PL
-----------------------------------------------------
City | NILES
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44446-4658
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-502-9177
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 135 ALLEN AVE
-----------------------------------------------------
City | COLUMBIANA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44408-1212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-502-9177
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 12036
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT016956
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------