Healthcare Provider Details

I. General information

NPI: 1073445292
Provider Name (Legal Business Name): KISSHA DIONNE MAYBERRY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3093 GLENAIRE DR
CINCINNATI OH
45251-2609
US

IV. Provider business mailing address

3093 GLENAIRE DR
CINCINNATI OH
45251-2609
US

V. Phone/Fax

Practice location:
  • Phone: 513-488-5921
  • Fax:
Mailing address:
  • Phone: 513-488-5921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: