1750384467 NPI number — MARY BETH LEAN PSY.D.

Table of content: MARY BETH LEAN PSY.D. (NPI 1750384467)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750384467 NPI number — MARY BETH LEAN PSY.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEAN
Provider First Name:
MARY BETH
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSY.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750384467
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8 SHOAL HOPE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST HARWICH
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02671-1615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-430-8672
Provider Business Mailing Address Fax Number:
508-430-9821

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
537 ROUTE 28
Provider Second Line Business Practice Location Address:
STE 2G
Provider Business Practice Location Address City Name:
HARWICH PORT
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02646-1894
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-430-8672
Provider Business Practice Location Address Fax Number:
508-430-9821
Provider Enumeration Date:
05/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  6839 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0501514 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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