Provider Demographics
NPI:1639392129
Name:MAYBERRY, JOHN D (MA LMFT)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:D
Last Name:MAYBERRY
Suffix:
Gender:M
Credentials:MA LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3225 GOLD DUST DR
Mailing Address - Street 2:
Mailing Address - City:PIGEON FORGE
Mailing Address - State:TN
Mailing Address - Zip Code:37863
Mailing Address - Country:US
Mailing Address - Phone:865-429-2375
Mailing Address - Fax:865-774-7877
Practice Address - Street 1:3225 GOLD DUST DR
Practice Address - Street 2:
Practice Address - City:PIGEON FORGE
Practice Address - State:TN
Practice Address - Zip Code:37863
Practice Address - Country:US
Practice Address - Phone:865-429-2375
Practice Address - Fax:865-774-7877
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLMT0000000240106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4041685OtherMAGELLAN HEALTH SERVICES