Provider Demographics
NPI:1164883526
Name:MAYBERRY, SAMANTHA ARIEL (DC)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:ARIEL
Last Name:MAYBERRY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7012 KINGSMILL CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-7387
Mailing Address - Country:US
Mailing Address - Phone:217-483-1551
Mailing Address - Fax:
Practice Address - Street 1:7012 KINGSMILL CT
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711-7387
Practice Address - Country:US
Practice Address - Phone:217-483-1551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-14
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038012923111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor