Basic Information
| Provider Information | |||||||||
| NPI: | 1184998171 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAYWARD | ||||||||
| FirstName: | BARBARA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | LPC, CCS, CAADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1956 BOSTON ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495064169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167760891 | ||||||||
| FaxNumber: | 6162439854 | ||||||||
| Practice Location | |||||||||
| Address1: | 1956 BOSTON ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167760891 | ||||||||
| FaxNumber: | 6162439854 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2012 | ||||||||
| LastUpdateDate: | 03/08/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401010152 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 6401010152 | 01 | MI | MICHIGAN LICENSE LPC | OTHER | S20108 | 01 | MI | MICHIGAN CERTIFICATION BOARD FOR ADDICTION PROFESSIONALS CCS | OTHER | C00736 | 01 | MI | MICHIGAN CERTIFICATION BOARD FOR ADDICTION PROFESSIONALS CAADC | OTHER |