Provider Demographics
NPI:1487275285
Name:MAYBERRY, KATHLEEN M (ATC)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:M
Last Name:MAYBERRY
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:M
Other - Last Name:MAYBERRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:515 ROANOKE DR
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-2521
Mailing Address - Country:US
Mailing Address - Phone:618-980-5605
Mailing Address - Fax:
Practice Address - Street 1:515 ROANOKE DR
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-2521
Practice Address - Country:US
Practice Address - Phone:618-980-5605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-03
Last Update Date:2020-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0041772255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer