Provider Demographics
NPI:1932414695
Name:MEDVIDE, MARY BETH (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:BETH
Last Name:MEDVIDE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:431 RIVER ST
Mailing Address - Street 2:STE., 1
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-5476
Mailing Address - Country:US
Mailing Address - Phone:781-966-5654
Mailing Address - Fax:781-701-8905
Practice Address - Street 1:431 RIVER ST
Practice Address - Street 2:STE., 1
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-5476
Practice Address - Country:US
Practice Address - Phone:781-966-5654
Practice Address - Fax:781-701-8905
Is Sole Proprietor?:No
Enumeration Date:2010-08-18
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10449103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling