Basic Information
| Provider Information | |||||||||
| NPI: | 1285978791 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAYNARD | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 208 W MAIN CROSS ST | ||||||||
| Address2: | P O BOX 35 | ||||||||
| City: | MILLER CITY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458640035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198763959 | ||||||||
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| Practice Location | |||||||||
| Address1: | 303 N HURSTBOURNE PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402225158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024125847 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2012 | ||||||||
| LastUpdateDate: | 11/21/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 012447 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.