Provider Demographics
NPI:1497565766
Name:MAYNARD, HOLDEN RADDE (PT)
Entity type:Individual
Prefix:
First Name:HOLDEN
Middle Name:RADDE
Last Name:MAYNARD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14890
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:579 TROY SCHENECTADY RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-2819
Practice Address - Country:US
Practice Address - Phone:518-382-4593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-09
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053043225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist