Healthcare Provider Details

I. General information

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

II. Dates (important events)

Enumeration Date: 07/30/2021
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

348 S WAVERLY RD STE 103
HOLLAND MI
49423-8101
US

IV. Provider business mailing address

790 SOUTHGATE ST
HOLLAND MI
49423-4557
US

V. Phone/Fax

Practice location:
  • Phone: 616-218-4769
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401223768
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: