Healthcare Provider Details

I. General information

NPI: 1972956530
Provider Name (Legal Business Name): KERMINDRA L MABERRY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KERMINDRA L MABERRY LCSW

II. Dates (important events)

Enumeration Date: 07/19/2016
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61540 BENNETT RD
AMITE LA
70422-4356
US

IV. Provider business mailing address

61540 BENNETT RD
AMITE LA
70422-4356
US

V. Phone/Fax

Practice location:
  • Phone: 985-474-4958
  • Fax:
Mailing address:
  • Phone: 985-474-4958
  • Fax: 985-318-7617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12866
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: