MEDICARE: MS. SUSANNE LYNN MAYNARD LMSW,MT-BC

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	225A00000X	Music Therapist	08861	TX
2	104100000X	Social Worker	59606	TX
3	171M00000X	Case Manager/Care Coordinator	59606	TX

General Provider Information

NPI Number	:	1669762241
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUSANNE LYNN MAYNARD LMSW,MT-BC

Provider Business Mailing Address
First Line	:	203 E MAPLE ST
Second Line	:
City	:	KEENE
State	:	TX
Zip	:	76059-2351
Country	:	US
Telephone Number	:	817-897-5598
Fax Number	:

Provider Business Practice Location Address
First Line	:	203 E MAPLE ST
Second Line	:
City	:	KEENE
State	:	TX
Zip	:	76059-2351
Country	:	US
Telephone Number	:	817-897-5598
Fax Number	:

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

Provider Enumeration Date	:	04/15/2011
Last Update Date	:	02/03/2015

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