Provider Demographics
NPI:1609948678
Name:MAYBERRY, ROSS LOWELL (PHD)
Entity Type:Individual
Prefix:MR
First Name:ROSS
Middle Name:LOWELL
Last Name:MAYBERRY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1402 10TH PL N
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98020-2629
Mailing Address - Country:US
Mailing Address - Phone:206-735-9592
Mailing Address - Fax:206-323-7324
Practice Address - Street 1:1402 10TH PL N
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98020-2629
Practice Address - Country:US
Practice Address - Phone:206-735-9592
Practice Address - Fax:206-323-7324
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPSY 1297103TC1900X
WAWAPSY1297103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
91-1985428OtherTAX ID #