Provider Demographics
NPI:1366027310
Name:BRANCH, MARY (PTA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BRANCH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:GILLESPIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:440 MERCHANT DR
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-6470
Mailing Address - Country:US
Mailing Address - Phone:405-809-8713
Mailing Address - Fax:
Practice Address - Street 1:815 NW 12TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73106-6802
Practice Address - Country:US
Practice Address - Phone:405-231-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-11
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK2892OtherPTA LICENSE