Provider Demographics
NPI:1336697606
Name:MAYBERN, SAMANTHA (LCSW-A)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:MAYBERN
Suffix:
Gender:F
Credentials:LCSW-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2212 HOPE MILLS RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-4228
Mailing Address - Country:US
Mailing Address - Phone:337-353-4056
Mailing Address - Fax:
Practice Address - Street 1:4020 FOLKER ST
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5321
Practice Address - Country:US
Practice Address - Phone:907-563-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-15
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NCP0130451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health