Provider Demographics
NPI:1255503330
Name:SOLIS-ALTAVAS, MARY GRACE Y (PT)
Entity Type:Individual
Prefix:MRS
First Name:MARY GRACE
Middle Name:Y
Last Name:SOLIS-ALTAVAS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3713 OAK HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-7478
Mailing Address - Country:US
Mailing Address - Phone:503-554-9318
Mailing Address - Fax:
Practice Address - Street 1:5860 GOLDEN GATE PKWY
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34116-7459
Practice Address - Country:US
Practice Address - Phone:239-455-9525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-28
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT239012251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics