Provider Demographics
NPI:1275816399
Name:AVILES, MARY ANN
Entity Type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:AVILES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 MARYLAND ROAD
Mailing Address - Street 2:B6
Mailing Address - City:WILLOW GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19090-1850
Mailing Address - Country:US
Mailing Address - Phone:215-771-1788
Mailing Address - Fax:
Practice Address - Street 1:857 W. WALNUT STREET
Practice Address - Street 2:
Practice Address - City:COAL TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:17866-1517
Practice Address - Country:US
Practice Address - Phone:215-771-1788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-25
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT021578225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist