Provider Demographics
NPI:1083871719
Name:CLEVELAND, MARY LOUISE
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:LOUISE
Last Name:CLEVELAND
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 1:12607 SE MILL PLAIN BLVD
Mailing Address - Street 2:PHYSICAL THERAPY
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98694-4098
Mailing Address - Country:US
Mailing Address - Phone:360-944-2807
Mailing Address - Fax:360-891-6297
Practice Address - Street 1:12607 SE MILL PLAIN BLVD
Practice Address - Street 2:PHYSICAL THERAPY DEPARTMENT
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-6055
Practice Address - Country:US
Practice Address - Phone:360-944-2807
Practice Address - Fax:360-891-6297
Is Sole Proprietor?:No
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8022225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist