Healthcare Provider Details

I. General information

NPI: 1851079131
Provider Name (Legal Business Name): KARIN ELIZABETH MAYBERRY PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2023
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 EXECUTIVE DR STE 300
FAIRVIEW HEIGHTS IL
62208-1345
US

IV. Provider business mailing address

8 EXECUTIVE DR STE 300
FAIRVIEW HEIGHTS IL
62208-1345
US

V. Phone/Fax

Practice location:
  • Phone: 618-688-4727
  • Fax: 618-688-7039
Mailing address:
  • Phone: 618-688-4727
  • Fax: 618-688-7039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: