Provider Demographics
NPI:1679613301
Name:MAYNARD, MICHELLE (MPT, DPT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:MPT, DPT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:BOURKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT,DPT
Mailing Address - Street 1:550 SAINT CHARLES DR
Mailing Address - Street 2:SUITE #100
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-3951
Mailing Address - Country:US
Mailing Address - Phone:805-777-1023
Mailing Address - Fax:805-777-3493
Practice Address - Street 1:550 SAINT CHARLES DR
Practice Address - Street 2:SUITE #100
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-3951
Practice Address - Country:US
Practice Address - Phone:805-777-1023
Practice Address - Fax:805-777-3493
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT28047225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT28047AMedicare ID - Type UnspecifiedMEDICARE PROVIDER ID NUMB