Healthcare Provider Details

I. General information

NPI: 1790901197
Provider Name (Legal Business Name): MARYBETH JUDY MS, RDN, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 01/08/2021
Certification Date: 01/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 SCHOOL HOUSE RD STE 14
ORLAND ME
04472-3966
US

IV. Provider business mailing address

21 SCHOOL HOUSE RD STE 14
ORLAND ME
04472-3966
US

V. Phone/Fax

Practice location:
  • Phone: 207-752-2341
  • Fax: 855-752-0261
Mailing address:
  • Phone: 207-752-2341
  • Fax: 855-752-0261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD1408
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: