Provider Demographics
NPI:1255791893
Name:MAYBERRY, ELLEN (RMP)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:MAYBERRY
Suffix:
Gender:F
Credentials:RMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2503 DENNIS AVE
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20902-4920
Mailing Address - Country:US
Mailing Address - Phone:301-801-8391
Mailing Address - Fax:
Practice Address - Street 1:2503 DENNIS AVE
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20902-4920
Practice Address - Country:US
Practice Address - Phone:301-801-8391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-24
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR01124225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist