Provider Demographics
NPI:1932559317
Name:VANDIVER, MARY BETH
Entity Type:Individual
Prefix:
First Name:MARY BETH
Middle Name:
Last Name:VANDIVER
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 1:338 RANCHLAND RD
Mailing Address - Street 2:
Mailing Address - City:BELDEN
Mailing Address - State:MS
Mailing Address - Zip Code:38826-9370
Mailing Address - Country:US
Mailing Address - Phone:205-399-1754
Mailing Address - Fax:
Practice Address - Street 1:2434 S EASON BLVD
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-6942
Practice Address - Country:US
Practice Address - Phone:662-640-4595
Practice Address - Fax:662-680-6416
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health