Provider Demographics
NPI:1689494940
Name:MAYBERRY, LAUREN
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:MAYBERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8098 PRECINCT LINE RD STE 110
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-7694
Mailing Address - Country:US
Mailing Address - Phone:817-778-9232
Mailing Address - Fax:
Practice Address - Street 1:8098 PRECINCT LINE RD STE 110
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-7694
Practice Address - Country:US
Practice Address - Phone:817-778-9232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-11
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX89101101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional