Provider Demographics
NPI:1174163463
Name:KRIS MAYNARD LCSW LTD
Entity type:Organization
Organization Name:KRIS MAYNARD LCSW LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:KRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYNARD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:708-921-3639
Mailing Address - Street 1:1030 S LA GRANGE RD STE 9
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-2893
Mailing Address - Country:US
Mailing Address - Phone:708-921-3639
Mailing Address - Fax:708-588-1501
Practice Address - Street 1:1030 S LA GRANGE RD STE 9
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-2893
Practice Address - Country:US
Practice Address - Phone:708-921-3639
Practice Address - Fax:708-588-1501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-14
Last Update Date:2021-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)