Provider Demographics
NPI:1437584620
Name:MAYBERRY, LESHEKA
Entity Type:Individual
Prefix:
First Name:LESHEKA
Middle Name:
Last Name:MAYBERRY
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 1:4412 COLUMBUS TRL
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133-7465
Mailing Address - Country:US
Mailing Address - Phone:469-685-3473
Mailing Address - Fax:
Practice Address - Street 1:4412 COLUMBUS TRL
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76133-7465
Practice Address - Country:US
Practice Address - Phone:469-685-3473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-06
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251C00000XAgenciesDay Training, Developmentally Disabled Services