Provider Demographics
NPI:1093734261
Name:BARTOLOME, MARY GLOAN M (PT)
Entity Type:Individual
Prefix:
First Name:MARY GLOAN
Middle Name:M
Last Name:BARTOLOME
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17233 N HOLMES BLVD
Mailing Address - Street 2:STE 1650
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-2030
Mailing Address - Country:US
Mailing Address - Phone:602-547-1836
Mailing Address - Fax:
Practice Address - Street 1:14200 W CELEBRATE LIFE WAY
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-3007
Practice Address - Country:US
Practice Address - Phone:623-207-3829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7531225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ192837Medicaid
AZ192837Medicaid