Healthcare Provider Details

I. General information

NPI: 1043314339
Provider Name (Legal Business Name): MARY M WETHERBY PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3425 LAKE ALFRED RD WINTER HAVEN HOSPITAL INC REHABILITATION SERVICES
WINTER HAVEN FL
33881-1445
US

IV. Provider business mailing address

200 AVENUE F NE WINTER HAVEN HOSPITAL INC
WINTER HAVEN FL
33881
US

V. Phone/Fax

Practice location:
  • Phone: 863-292-4060
  • Fax: 863-293-6985
Mailing address:
  • Phone: 863-293-1121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY6337
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: