Provider Demographics
NPI:1043314339
Name:WETHERBY, MARY M (PHD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:WETHERBY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:200 AVENUE F NE
Mailing Address - Street 2:WINTER HAVEN HOSPITAL INC
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881
Mailing Address - Country:US
Mailing Address - Phone:863-293-1121
Mailing Address - Fax:
Practice Address - Street 1:3425 LAKE ALFRED RD
Practice Address - Street 2:WINTER HAVEN HOSPITAL INC REHABILITATION SERVICES
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-1445
Practice Address - Country:US
Practice Address - Phone:863-292-4060
Practice Address - Fax:863-293-6985
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6337103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist