Provider Demographics
NPI:1164077210
Name:AYALA, MARJORIE (PTA)
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:
Last Name:AYALA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3291 E MONTEZUMA AVE
Mailing Address - Street 2:
Mailing Address - City:RIMROCK
Mailing Address - State:AZ
Mailing Address - Zip Code:86335-5495
Mailing Address - Country:US
Mailing Address - Phone:928-863-4508
Mailing Address - Fax:
Practice Address - Street 1:86 W SALT MINE RD
Practice Address - Street 2:
Practice Address - City:CAMP VERDE
Practice Address - State:AZ
Practice Address - Zip Code:86322-7013
Practice Address - Country:US
Practice Address - Phone:928-567-5253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-06
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6915A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant