Healthcare Provider Details

I. General information

NPI: 1689494940
Provider Name (Legal Business Name): LAUREN MAYBERRY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2024
Last Update Date: 10/11/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8098 PRECINCT LINE RD STE 110
COLLEYVILLE TX
76034-7694
US

IV. Provider business mailing address

8098 PRECINCT LINE RD STE 110
COLLEYVILLE TX
76034-7694
US

V. Phone/Fax

Practice location:
  • Phone: 817-778-9232
  • Fax:
Mailing address:
  • Phone: 817-778-9232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number89101
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: