Provider Demographics
NPI:1558557710
Name:MAYBERRY, ROSHELL D
Entity Type:Individual
Prefix:
First Name:ROSHELL
Middle Name:D
Last Name:MAYBERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ROSHELL
Other - Middle Name:D
Other - Last Name:MAYBERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9337 S 94TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-5642
Mailing Address - Country:US
Mailing Address - Phone:918-237-1141
Mailing Address - Fax:
Practice Address - Street 1:9337 S 94TH EAST AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-5642
Practice Address - Country:US
Practice Address - Phone:918-237-1141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator