Healthcare Provider Details

I. General information

NPI: 1205494770
Provider Name (Legal Business Name): PHILLIP EDWARD MAYBERY CSAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2019
Last Update Date: 05/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1258 HOLLAND RD
SUFFOLK VA
23434-6313
US

IV. Provider business mailing address

55 BEATTIE PL STE 810
GREENVILLE SC
29601-2191
US

V. Phone/Fax

Practice location:
  • Phone: 757-439-2698
  • Fax:
Mailing address:
  • Phone: 864-527-3145
  • 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: