Provider Demographics
NPI:1144796772
Name:KNOWLTON, MARY (PTA, LMT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:KNOWLTON
Suffix:
Gender:F
Credentials:PTA, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 JAYBEE AVE
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33897-5452
Mailing Address - Country:US
Mailing Address - Phone:321-297-5345
Mailing Address - Fax:
Practice Address - Street 1:2520 SAND MINE RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33897-3402
Practice Address - Country:US
Practice Address - Phone:863-576-1900
Practice Address - Fax:407-386-7893
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA28699225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant