Provider Demographics
NPI:1932453305
Name:MAYNOR, COURTNEY LYN (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:LYN
Last Name:MAYNOR
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1047 DAVIS CREEK LN
Mailing Address - Street 2:
Mailing Address - City:DU QUOIN
Mailing Address - State:IL
Mailing Address - Zip Code:62832-3738
Mailing Address - Country:US
Mailing Address - Phone:618-542-3496
Mailing Address - Fax:
Practice Address - Street 1:306 W MILL ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-2727
Practice Address - Country:US
Practice Address - Phone:618-529-3060
Practice Address - Fax:618-457-5372
Is Sole Proprietor?:No
Enumeration Date:2012-11-06
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.005077225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist