Basic Information
| Provider Information | |||||||||
| NPI: | 1497117287 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAYNARD | ||||||||
| FirstName: | EBONY | ||||||||
| MiddleName: | TAGUA HIDIE | ||||||||
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| Credential: | LCSW-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 604 SOLAREX CT | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217037005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016638263 | ||||||||
| FaxNumber: | 3016825326 | ||||||||
| Practice Location | |||||||||
| Address1: | 604 SOLAREX CT | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217037005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016638263 | ||||||||
| FaxNumber: | 3016825326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2016 | ||||||||
| LastUpdateDate: | 07/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 18946 | MD | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.