Provider Demographics
NPI:1275653792
Name:HERBERT, MARY ELIZABETH (RD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:HERBERT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FULTON ST
Mailing Address - Street 2:
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-5219
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:41 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:MA
Practice Address - Zip Code:01890-1446
Practice Address - Country:US
Practice Address - Phone:781-756-2615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMT0644133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered