Provider Demographics
NPI:1962787457
Name:BAILAR-HEATH, MARY BETH (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARY BETH
Middle Name:
Last Name:BAILAR-HEATH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:MARYBETH
Other - Middle Name:
Other - Last Name:BAILAR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:100 MAGNOLIA RD STE 2229
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-9820
Mailing Address - Country:US
Mailing Address - Phone:910-420-4790
Mailing Address - Fax:910-320-8890
Practice Address - Street 1:100 MAGNOLIA RD STE 2229
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-9820
Practice Address - Country:US
Practice Address - Phone:910-420-4790
Practice Address - Fax:910-320-8890
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003293103G00000X
NC4639103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ47737C886Medicare PIN