Provider Demographics
NPI:1346216678
Name:PETERSON, MARY C (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7464 WINCHESTER RD
Mailing Address - Street 2:STE 103
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38125-2205
Mailing Address - Country:US
Mailing Address - Phone:901-758-2377
Mailing Address - Fax:990-175-8110
Practice Address - Street 1:756 RIDGE LAKE BLVD
Practice Address - Street 2:STE 205
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-9445
Practice Address - Country:US
Practice Address - Phone:901-758-2377
Practice Address - Fax:990-175-8110
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN2051225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I651035Medicare PIN
TN3730201Medicare PIN