Provider Demographics
NPI:1487034526
Name:MABERRY, KATIE
Entity Type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:
Last Name:MABERRY
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 1:615 E ASH ST
Mailing Address - Street 2:
Mailing Address - City:OKAWVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62271-2229
Mailing Address - Country:US
Mailing Address - Phone:618-237-3720
Mailing Address - Fax:
Practice Address - Street 1:1700 WHITE ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-4349
Practice Address - Country:US
Practice Address - Phone:618-242-4075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-03
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.011653235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist