MEDICARE: TRISTAN LEIGH MAYNARD LSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	S.2513149	OH

General Provider Information

NPI Number	:	1285566919
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRISTAN LEIGH MAYNARD LSW

Provider Business Mailing Address
First Line	:	5123 NORWICH ST STE 110
Second Line	:
City	:	HILLIARD
State	:	OH
Zip	:	43026-1486
Country	:	US
Telephone Number	:	877-244-3219
Fax Number	:	614-467-3546

Provider Business Practice Location Address
First Line	:	5123 NORWICH ST STE 110
Second Line	:
City	:	HILLIARD
State	:	OH
Zip	:	43026-1486
Country	:	US
Telephone Number	:	877-244-3219
Fax Number	:	614-467-3546

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/29/2026
Last Update Date	:	05/29/2026

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