Provider Demographics
NPI:1861946071
Name:MAYBERRY, SUSAN DAWN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:DAWN
Last Name:MAYBERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 VALLEY ST
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:IA
Mailing Address - Zip Code:51534-1024
Mailing Address - Country:US
Mailing Address - Phone:712-527-1064
Mailing Address - Fax:
Practice Address - Street 1:801 HARMONY ST STE 302
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-3106
Practice Address - Country:US
Practice Address - Phone:712-328-2609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-05
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA20R002101YA0400X
NE1314101YA0400X
IA099212101YM0800X
NE2243101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)