MEDICARE: MS. LIDIA I MAYNEZ LPC

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	101YP2500X	Professional Counselor	18013	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6204LC	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1760517197
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LIDIA I MAYNEZ LPC

Provider Business Mailing Address
First Line	:	6623 DAWN DR APT A
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79912-2970
Country	:	US
Telephone Number	:	915-449-1634
Fax Number	:

Provider Business Practice Location Address
First Line	:	4100 RIO BRAVO ST STE 311
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79902-1049
Country	:	US
Telephone Number	:	915-449-5694
Fax Number	:

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

Provider Enumeration Date	:	02/23/2007
Last Update Date	:	07/08/2007

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