Provider Demographics
NPI:1780824276
Name:MAYBERRY, PEGGY L (LCSW)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:L
Last Name:MAYBERRY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 SERGEANT PRENTISS DR
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-4726
Mailing Address - Country:US
Mailing Address - Phone:601-443-2139
Mailing Address - Fax:
Practice Address - Street 1:54 SERGEANT PRENTISS DR
Practice Address - Street 2:
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-4726
Practice Address - Country:US
Practice Address - Phone:601-443-2139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-24
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC1997171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator