Provider Demographics
NPI:1114932803
Name:REIDHEAD, MARY D (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:D
Last Name:REIDHEAD
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 1:1221 W WARNER RD STE 102
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-1906
Mailing Address - Country:US
Mailing Address - Phone:480-735-0124
Mailing Address - Fax:480-735-0126
Practice Address - Street 1:1221 W WARNER RD STE 102
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85284-1906
Practice Address - Country:US
Practice Address - Phone:480-735-0124
Practice Address - Fax:480-735-0126
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4116225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ8HC888Medicare ID - Type UnspecifiedCIBECUE
AZ8HC887Medicare ID - Type UnspecifiedWHITERIVER