Provider Demographics
NPI:1275234783
Name:VASQUEZ, MARJORIE ANN SIMBULAN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MARJORIE ANN
Middle Name:SIMBULAN
Last Name:VASQUEZ
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 ASSOCIATION DR STE 102
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25311-1298
Mailing Address - Country:US
Mailing Address - Phone:304-388-0015
Mailing Address - Fax:304-388-0019
Practice Address - Street 1:3200 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1297
Practice Address - Country:US
Practice Address - Phone:304-388-4233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-13
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV003967225100000X
WVPT003967225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist