Provider Demographics
NPI:1376667600
Name:LUDLOFF, MARY SHANNON (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SHANNON
Last Name:LUDLOFF
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 1:4103 N VIKING WAY
Mailing Address - Street 2:STE C
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808-1490
Mailing Address - Country:US
Mailing Address - Phone:615-778-4066
Mailing Address - Fax:615-778-9114
Practice Address - Street 1:4103 N VIKING WAY
Practice Address - Street 2:STE C
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90808-1490
Practice Address - Country:US
Practice Address - Phone:615-778-4066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19911225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist