=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760517197
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LIDIA I MAYNEZ LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4100 RIO BRAVO ST STE 311
-----------------------------------------------------
City | EL PASO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79902-1049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-449-5694
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6623 DAWN DR APT A
-----------------------------------------------------
City | EL PASO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79912-2970
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-449-1634
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 18013
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------