Provider Demographics
NPI:1730271834
Name:MABRY, MAX R (CCC/FA)
Entity type:Individual
Prefix:
First Name:MAX
Middle Name:R
Last Name:MABRY
Suffix:
Gender:M
Credentials:CCC/FA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WI
Mailing Address - Zip Code:24740
Mailing Address - Country:US
Mailing Address - Phone:304-425-8058
Mailing Address - Fax:
Practice Address - Street 1:1242 HOCKMAN PIKE
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:VA
Practice Address - Zip Code:24605-9351
Practice Address - Country:US
Practice Address - Phone:276-326-3890
Practice Address - Fax:276-322-1514
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2201001323231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3967049Medicare ID - Type Unspecified