Provider Demographics
NPI:1669777447
Name:MAYBERRY, TINA LEA (SLP)
Entity type:Individual
Prefix:MS
First Name:TINA
Middle Name:LEA
Last Name:MAYBERRY
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:MC LEANSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62859-1231
Mailing Address - Country:US
Mailing Address - Phone:618-643-5005
Mailing Address - Fax:618-241-7039
Practice Address - Street 1:107 SUNSET DR
Practice Address - Street 2:
Practice Address - City:MC LEANSBORO
Practice Address - State:IL
Practice Address - Zip Code:62859-1231
Practice Address - Country:US
Practice Address - Phone:618-643-5005
Practice Address - Fax:618-241-7039
Is Sole Proprietor?:No
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146005061235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist