Provider Demographics
NPI:1982910311
Name:PRIDE, MARYBETH DAVIS (CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:MARYBETH
Middle Name:DAVIS
Last Name:PRIDE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04841-3146
Mailing Address - Country:US
Mailing Address - Phone:207-208-7233
Mailing Address - Fax:
Practice Address - Street 1:78 CEDAR ST
Practice Address - Street 2:
Practice Address - City:ROCKLAND
Practice Address - State:ME
Practice Address - Zip Code:04841-3146
Practice Address - Country:US
Practice Address - Phone:207-208-7233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-23
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP1303235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME263810000Medicaid