Provider Demographics
NPI:1104030469
Name:REISCHL, MARY M (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:REISCHL
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 1:2008 VIA AGUILA
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-5670
Mailing Address - Country:US
Mailing Address - Phone:949-361-3584
Mailing Address - Fax:
Practice Address - Street 1:1151 PUERTA DEL SOL
Practice Address - Street 2:SUITE B
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-6311
Practice Address - Country:US
Practice Address - Phone:949-481-0015
Practice Address - Fax:949-481-5611
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT10257225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT10257AMedicare ID - Type Unspecified