Provider Demographics
NPI:1093201394
Name:ROBERTS, MARY FAY (DPT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:FAY
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2635 NW ROLLING GREEN DR
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3519
Mailing Address - Country:US
Mailing Address - Phone:541-753-4246
Mailing Address - Fax:
Practice Address - Street 1:2635 NW ROLLING GREEN DR
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3519
Practice Address - Country:US
Practice Address - Phone:541-753-4246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR62790225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist