Provider Demographics
NPI:1528181013
Name:PAYNE, MARYBETH
Entity Type:Individual
Prefix:
First Name:MARYBETH
Middle Name:
Last Name:PAYNE
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 1:101 E 6TH ST
Mailing Address - Street 2:P.O. BOX 1506
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16501-1201
Mailing Address - Country:US
Mailing Address - Phone:814-459-2755
Mailing Address - Fax:814-456-4873
Practice Address - Street 1:101 E 6TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16501-1201
Practice Address - Country:US
Practice Address - Phone:814-459-2755
Practice Address - Fax:814-456-4873
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC-001382-L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty