Provider Demographics
NPI:1275564056
Name:HART, MARY GERLOCK (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:GERLOCK
Last Name:HART
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 1:3385 MAGIC OAK LN
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34232-1821
Mailing Address - Country:US
Mailing Address - Phone:941-706-4447
Mailing Address - Fax:941-706-4481
Practice Address - Street 1:3385 MAGIC OAK LN
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34232-1821
Practice Address - Country:US
Practice Address - Phone:941-706-4447
Practice Address - Fax:941-706-4481
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT21618225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY090ZOtherBLUE CROSS BLUE SHIELD
FLY090ZOtherBLUE CROSS BLUE SHIELD