Provider Demographics
NPI:1134501927
Name:CHURBOCK, MARY BETH (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:CHURBOCK
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 1:2002 JOHNSON ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:JENNINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70546-3640
Mailing Address - Country:US
Mailing Address - Phone:337-824-4547
Mailing Address - Fax:337-824-4548
Practice Address - Street 1:308 SIDNEY MARTIN RD
Practice Address - Street 2:ROOM 174
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70507-4544
Practice Address - Country:US
Practice Address - Phone:337-233-3665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-29
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA00325225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist