Provider Demographics
NPI:1326258294
Name:ESTRADA, MARY E
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:ESTRADA
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 1:506 E PEARL ST
Mailing Address - Street 2:
Mailing Address - City:GENESEO
Mailing Address - State:IL
Mailing Address - Zip Code:61254-1560
Mailing Address - Country:US
Mailing Address - Phone:815-541-4403
Mailing Address - Fax:
Practice Address - Street 1:250 INTERNATIONAL PKWY
Practice Address - Street 2:STE 260
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-5030
Practice Address - Country:US
Practice Address - Phone:800-806-6026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1072019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant