Provider Demographics
NPI:1295028256
Name:MAYBERRY, KOHL MITCHELL (DO)
Entity Type:Individual
Prefix:DR
First Name:KOHL
Middle Name:MITCHELL
Last Name:MAYBERRY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 RANDALL RD STE 308
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-4205
Mailing Address - Country:US
Mailing Address - Phone:630-933-4056
Mailing Address - Fax:630-208-3007
Practice Address - Street 1:1335 N MILL ST STE 100
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-2047
Practice Address - Country:US
Practice Address - Phone:630-305-5027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-24
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.1561052084P0800X
IL0361561052084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007622900Medicaid
FL007622900Medicaid
FLHO714YMedicare PIN