Provider Demographics
NPI:1417419847
Name:MAYBERRY, PAGE ELLEN (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:PAGE
Middle Name:ELLEN
Last Name:MAYBERRY
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8734 BLUEBIRD DR
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45069-3458
Mailing Address - Country:US
Mailing Address - Phone:513-504-7650
Mailing Address - Fax:
Practice Address - Street 1:1120 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IN
Practice Address - Zip Code:47960-1500
Practice Address - Country:US
Practice Address - Phone:574-583-7073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-04
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28687235Z00000X
COSLP.0003603235Z00000X
OHSP.13902235Z00000X
AZSLP12090235Z00000X
IN22007142A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist