Provider Demographics
NPI:1689861254
Name:MABERY, KATRINA ALLYSON
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:ALLYSON
Last Name:MABERY
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 1:3716 MELROSE AVE NW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24017-2716
Mailing Address - Country:US
Mailing Address - Phone:540-362-0360
Mailing Address - Fax:540-366-2049
Practice Address - Street 1:3716 MELROSE AVE NW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24017-2716
Practice Address - Country:US
Practice Address - Phone:540-540-3620
Practice Address - Fax:540-366-2049
Is Sole Proprietor?:No
Enumeration Date:2007-09-27
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040066381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004945263Medicaid