Provider Demographics
NPI:1225260060
Name:HOSTETTER, MARY C (DPT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:HOSTETTER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3978 NEW VISION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1712
Practice Address - Country:US
Practice Address - Phone:260-373-9318
Practice Address - Fax:260-373-9301
Is Sole Proprietor?:No
Enumeration Date:2009-08-12
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05009901A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200965610AMedicaid
IN156546OtherGROUP MEDICARE
IN100257920HOtherGROUP MEDICAID