Provider Demographics
NPI:1134491251
Name:PRANCKUS, MARY (PT ASSISTANT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:PRANCKUS
Suffix:
Gender:F
Credentials:PT ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 HANDEL RD
Mailing Address - Street 2:
Mailing Address - City:STAFFORD SPRINGS
Mailing Address - State:CT
Mailing Address - Zip Code:06076-4032
Mailing Address - Country:US
Mailing Address - Phone:860-875-6272
Mailing Address - Fax:
Practice Address - Street 1:600 S BROAD ST
Practice Address - Street 2:
Practice Address - City:KENNETT SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19348-3346
Practice Address - Country:US
Practice Address - Phone:855-497-6449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-05
Last Update Date:2012-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT446225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant