Provider Demographics
NPI:1164507497
Name:ROLES, MARY GERTRUDE (PTA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:GERTRUDE
Last Name:ROLES
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 1:4115 4TH ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21225-2326
Mailing Address - Country:US
Mailing Address - Phone:410-638-0700
Mailing Address - Fax:
Practice Address - Street 1:2217 COMMERCE RD
Practice Address - Street 2:
Practice Address - City:FOREST HILL
Practice Address - State:MD
Practice Address - Zip Code:21050-2565
Practice Address - Country:US
Practice Address - Phone:410-638-0700
Practice Address - Fax:410-638-6790
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA1850225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant