Provider Demographics
NPI:1346540804
Name:DIZON, MARY AUDREY (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:AUDREY
Last Name:DIZON
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 1:1306 MEAGHAN DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-1840
Mailing Address - Country:US
Mailing Address - Phone:217-417-9731
Mailing Address - Fax:
Practice Address - Street 1:1505 PATTON DR
Practice Address - Street 2:
Practice Address - City:MAHOMET
Practice Address - State:IL
Practice Address - Zip Code:61853-8116
Practice Address - Country:US
Practice Address - Phone:217-586-3749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-29
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070015799225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist