Provider Demographics
NPI:1154818011
Name:IRVIN, MARY (ATC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:IRVIN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:PATRICIA
Other - Last Name:IRVIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:14959 SAGECREST CT
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-6888
Mailing Address - Country:US
Mailing Address - Phone:574-247-1154
Mailing Address - Fax:
Practice Address - Street 1:5215 HOLY CROSS PKWY
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1469
Practice Address - Country:US
Practice Address - Phone:574-258-9539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001360A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer