Provider Demographics
NPI:1164552634
Name:ROMERO, MARY L (MPT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:ROMERO
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9550 W VAN BUREN ST
Mailing Address - Street 2:SUITE 14 A
Mailing Address - City:TOLLESON
Mailing Address - State:AZ
Mailing Address - Zip Code:85353-2826
Mailing Address - Country:US
Mailing Address - Phone:623-322-4917
Mailing Address - Fax:623-322-8625
Practice Address - Street 1:9550 W VAN BUREN ST
Practice Address - Street 2:SUITE 14 A
Practice Address - City:TOLLESON
Practice Address - State:AZ
Practice Address - Zip Code:85353-2826
Practice Address - Country:US
Practice Address - Phone:623-322-4917
Practice Address - Fax:623-322-8625
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5948225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ094354Medicaid
AZ094354Medicaid