Provider Demographics
NPI:1215375126
Name:DISTRETTI, MARY GRACE (DPT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:GRACE
Last Name:DISTRETTI
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:GRACE
Other - Last Name:YEAGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:PO BOX 306393
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37230-6393
Mailing Address - Country:US
Mailing Address - Phone:615-373-1350
Mailing Address - Fax:
Practice Address - Street 1:5220 PARK AVE STE 201
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-3549
Practice Address - Country:US
Practice Address - Phone:901-683-9630
Practice Address - Fax:901-767-2663
Is Sole Proprietor?:No
Enumeration Date:2013-06-13
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9655225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1336494103OtherGROUP NPI