Provider Demographics
NPI:1942829098
Name:SERVOS, MARIAH MARGARET
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:MARGARET
Last Name:SERVOS
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 1:108 AMHERST RD
Mailing Address - Street 2:
Mailing Address - City:PELHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01002-9799
Mailing Address - Country:US
Mailing Address - Phone:413-687-0594
Mailing Address - Fax:
Practice Address - Street 1:600 GRESHAM DR STE 1100
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1904
Practice Address - Country:US
Practice Address - Phone:757-388-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-09
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program