Provider Demographics
NPI:1134678865
Name:CHALAN, MARY JOYCE
Entity Type:Individual
Prefix:
First Name:MARY JOYCE
Middle Name:
Last Name:CHALAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 W ALAMEDA ST
Mailing Address - Street 2:APT A
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88203-4580
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 CHESTER RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VT
Practice Address - Zip Code:05156-2106
Practice Address - Country:US
Practice Address - Phone:802-885-5741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-22
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040.0101826225100000X
NMPT5162225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty