Healthcare Provider Details

I. General information

NPI: 1336812718
Provider Name (Legal Business Name): KEVIN GREG MAYBURY LLPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2021
Last Update Date: 07/30/2021
Certification Date: 07/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5020 E BELTLINE AVE NE SUITE 202
GRAND RAPIDS MI
49525
US

IV. Provider business mailing address

5020 E BELTLINE AVE NE SUITE 202
GRAND RAPIDS MI
49525
US

V. Phone/Fax

Practice location:
  • Phone: 616-439-1866
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401019425
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: