Healthcare Provider Details

I. General information

NPI: 1063686699
Provider Name (Legal Business Name): DEWEY SCOTT MAYBERRY M.A. LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2008
Last Update Date: 04/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4626 LORI LN
PACE FL
32571-1560
US

IV. Provider business mailing address

4626 LORI LN
PACE FL
32571-1560
US

V. Phone/Fax

Practice location:
  • Phone: 850-266-3025
  • Fax: 850-944-9676
Mailing address:
  • Phone: 850-266-3025
  • Fax: 850-944-9676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH7715
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: