Provider Demographics
NPI:1396311932
Name:BLOOD, MARYBETH
Entity type:Individual
Prefix:
First Name:MARYBETH
Middle Name:
Last Name:BLOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 E SHORE RD
Mailing Address - Street 2:
Mailing Address - City:DENVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07834-2026
Mailing Address - Country:US
Mailing Address - Phone:862-242-9412
Mailing Address - Fax:
Practice Address - Street 1:111 STATE ROUTE 35
Practice Address - Street 2:
Practice Address - City:CLIFFWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07721-1512
Practice Address - Country:US
Practice Address - Phone:732-727-2555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01123100363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0856924Medicaid