Provider Demographics
NPI:1346638657
Name:WESTERN, MARY BETH
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:BETH
Last Name:WESTERN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:BETH
Other - Last Name:PELLERITO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:23046 ITHACA ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-2213
Mailing Address - Country:US
Mailing Address - Phone:248-542-1628
Mailing Address - Fax:
Practice Address - Street 1:23046 ITHACA ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-2213
Practice Address - Country:US
Practice Address - Phone:248-224-6587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst