MEDICARE: LESHEKA MAYBERRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251B00000X	Case Management Agency
2	251C00000X	Developmentally Disabled Services Day Training Agency

General Provider Information

NPI Number	:	1437584620
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESHEKA MAYBERRY

Provider Business Mailing Address
First Line	:	4412 COLUMBUS TRL
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133-7465
Country	:	US
Telephone Number	:	469-685-3473
Fax Number	:

Provider Business Practice Location Address
First Line	:	4412 COLUMBUS TRL
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133-7465
Country	:	US
Telephone Number	:	469-685-3473
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/06/2013
Last Update Date	:	09/06/2013

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Directions to “ LESHEKA MAYBERRY ” Practice Location

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