Provider Demographics
NPI:1871894527
Name:MAYNARD, ELIZABETH BLAKE (PT, DPT)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:BLAKE
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 COMMERCIAL ST STE 4
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-5083
Mailing Address - Country:US
Mailing Address - Phone:603-225-5132
Mailing Address - Fax:
Practice Address - Street 1:28 COMMERCIAL ST STE 4
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301
Practice Address - Country:US
Practice Address - Phone:603-225-5132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-11
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040.0070090225100000X
NH3568225100000X
MA18989225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist